General Information
List All Household Drivers* Please click on the "+" to add more drivers.
Primary Email*
Primary Email*
Primary Phone Number* Primary Phone Number*
Preferred Contact Method* Dropdown Call Text Email
Mailing Address*
Mailing Address same as Home Address?*
Home Address*
Have you been at this address for at least 3 years?*
Previous Home Address*
Motorcycle Information
List All Motorcycles* Please click on the "+" to add another vehicle.
Annual mileage (or best estimate)* Dropdown 0 - 3,999 4,000 - 5,999 6,000 - 7,999 8,000 - 9,999 10,000 - 11,999 12,000 - 13,999 14,000 - 15,999 16,000 - 17,999 18,000 - 19,999 20,000 - 21,999 22,000 - 23,999 24,000 - 26,999 27,000 - 29,999 30,000 - 99,999 I'm not sure
Is there any existing damage to your motorcycle(s)?*
Please explain in detail* Please explain in detail*
Potential Discounts!
Save by bundling with your auto and home/renters?*
Car Information
Please click on the "+" to add another vehicle. Please click on the "+" to add another vehicle.
Annual mileage (or best estimate) Dropdown 0 - 3,999 4,000 - 5,999 6,000 - 7,999 8,000 - 9,999 10,000 - 11,999 12,000 - 13,999 14,000 - 15,999 16,000 - 17,999 18,000 - 19,999 20,000 - 21,999 22,000 - 23,999 24,000 - 26,999 27,000 - 29,999 30,000 - 99,999 I'm not sure
Is there any existing damage to your vehicle?
Please explain in detail Please explain in detail
Same home address as listed before?*
Address*
Are all household members the same as the drivers you've listed?*
List All Household Members* Please click on the "+" to add more members.
Year Built* Dropdown 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Pre-1900
Year Purchased* Dropdown 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Amount of personal property (or best estimate)* Dropdown $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $300,0000+
Number of stories (not including basement)* Dropdown 1 Story / Ranch 1.5 Stories 2 Stories 2.5 Stories 3 Stories Bi Level / Raised Ranch Tri Level
Is it sprinklered?*
Are there smoke alarms?*
Is there a fire extinguisher?*
Above ground square footage (or best estimate)* Above ground square footage (or best estimate)*
Type of basement* Dropdown Basement (below-grade) Basement (walkout) Slab-on-ground Crawl space None of the above I'm not sure
Basment % finished* Basment % finished*
Number of Full Bathrooms* Dropdown 1 2 3 4 5 6 7 8+
Number of Half Bathrooms* Dropdown 1 2 3 4 5 6 7 8+
Any ongoing repairs?*
Please explain in detail* Please explain in detail*
Any existing damage to your home?*
Please explain in detail* Please explain in detail*
Year Roof Replaced* Dropdown Original Roof 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Type of roof* Dropdown Shingles, Architectural Composite Shingle Metal None of the above I'm not sure
Year Wiring Updated* Dropdown Original Wiring 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Type of Wiring* Dropdown Copper Aluminum Knob & Tube Romex I'm not sure
Year Heating Updated* Dropdown Original Heating 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Primary Heating Source* Dropdown None Electric Gas Forced Air Heat Pump Oil Forced Air Propane Gas Forced Air Gas Hot Water Oil Hot Water Propane Gas Hot Water Radiant Floor Heating Geothermal, Closed Loop Geothermal, Open Loop I'm not sure
Year Plumbing Updated* Dropdown Original Plumbing 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Swimming Pool?* Dropdown None Yes, in-ground - fenced Yes, in-ground - not fenced Yes, above ground
Trampoline?* Dropdown None Yes, fenced Yes, not fenced
Deck?* Dropdown None Yes, wood deck Yes, composite Yes, concrete
Is there a wood burning stove?* Dropdown None Yes, attached to wall Yes, free standing
Does a business operate on the premises?*
Please explain in detail* Please explain in detail*
Do you own any pets?*
Please list all pets (for dogs please include breed)* Please list all pets (for dogs please include breed)*
If you own additional properties, please list addresses here If you own additional properties, please list addresses here
If you rent from additional properties, please list addresses and amount of personal property If you rent from additional properties, please list addresses and amount of personal property
Additional Information
Do you have a current motorcycle insurance policy?*
Date of Renewal*
Current motorcycle insurance company* Dropdown Acuity Allstate American Family Auto-Owners Erie Geico The General Germantown Grinnell Hastings Liberty Midwest Family Mt. Morris Nationwide Partners Mutual Pekin Progressive Rural Mutual Selective State Farm Travelers West Bend Other
Please specify company* Please specify company*
Cost per year for motorcycle insurance* Cost per year for motorcycle insurance*
Do you have a current car insurance policy?*
Date of Renewal*
Current car insurance company* Dropdown Acuity Allstate American Family Auto-Owners Erie Geico The General Germantown Grinnell Hastings Liberty Midwest Family Mt. Morris Nationwide Partners Mutual Pekin Progressive Rural Mutual Selective State Farm Travelers West Bend Other
Please specify company* Please specify company*
Cost per year for car insurance* Cost per year for car insurance*
Do you have a current homeowners/renters insurance policy?*
Date of Renewal*
Current homeowners/renters insurance company* Dropdown Acuity Allstate American Family Auto-Owners Erie Geico Germantown Grinnell Hastings Liberty Midwest Family Mt. Morris Nationwide Partners Mutual Pekin Progressive Rural Mutual Selective State Farm Travelers West Bend Other
Please specify company* Please specify company*
Cost per year for homeowners/renters insurance* Cost per year for homeowners/renters insurance*
How long have you had your driver's license?*
Have you had any claims in the last 5 years?*
Please explain in detail* Please explain in detail*
Additional comments, questions, or remarks Additional comments, questions, or remarks
This field is for validation purposes and should be left unchanged.
This field is for validation purposes and should be left unchanged.
