This field is for validation purposes and should be left unchanged.
This field is for validation purposes and should be left unchanged.
General Information
Name*
First Name*
Last Name*
Primary Email*
Primary Email*
Primary Phone Number* Primary Phone Number*
Preferred Contact Method*
List All Household Drivers* Please click on the "+" to add more drivers.
Are all household members the same as the drivers you've listed?*
List Additional Household Members* Please click on the "+" to add more members.
Mailing Address*
Mailing Address same as Home Address?*
Home Address*
Have you been at this address for at least 3 years?*
Previous Home Address*
Auto Information
List All Vehicles* 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*
Home Information
How many properties do you own?* 1 2 3
Same home address as listed before?*
Address*
Year Built* Year Built*
Year Purchased* Year Purchased*
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
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
Basement % finished* Basement % finished*
Number of Full Bathrooms* Number of Full Bathrooms*
Number of Half Bathrooms* Number of Half Bathrooms*
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* Year Roof Replaced*
Type of roof* Dropdown Shingles, Architectural Composite Shingle Metal None of the above I'm not sure
Year Wiring Updated* Year Wiring Updated*
Type of Wiring* Dropdown Copper Aluminum Knob & Tube Romex I'm not sure
Year Heating Updated* Year Heating Updated*
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* Year Plumbing Updated*
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
Wood burning stove?* Dropdown None Yes, attached to wall Yes, free standing
Home 2
Address*
Year Built* Year Built*
Year Purchased* Year Purchased*
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
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
Basement % finished* Basement % finished*
Number of Full Bathrooms* Number of Full Bathrooms*
Number of Half Bathrooms* Number of Half Bathrooms*
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* Year Roof Replaced*
Type of roof* Dropdown Shingles, Architectural Composite Shingle Metal None of the above I'm not sure
Year Wiring Updated* Year Wiring Updated*
Type of Wiring* Dropdown Copper Aluminum Knob & Tube Romex I'm not sure
Type of Wiring* Dropdown Copper Aluminum Knob & Tube Romex I'm not sure
Year Heating Updated* Year Heating Updated*
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* Year Plumbing Updated*
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
Wood burning stove?* Dropdown None Yes, attached to wall Yes, free standing
Home 3
Address*
Year Built* Year Built*
Year Purchased* Year Purchased*
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
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
Basement % finished* Basement % finished*
Number of Full Bathrooms* Number of Full Bathrooms*
Number of Half Bathrooms* Number of Half Bathrooms*
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* Year Roof Replaced*
Type of roof* Dropdown Shingles, Architectural Composite Shingle Metal None of the above I'm not sure
Year Wiring Updated* Year Wiring Updated*
Type of Wiring* Dropdown Copper Aluminum Knob & Tube Romex I'm not sure
Year Heating Updated* Year Heating Updated*
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* Year Plumbing Updated*
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
Wood burning stove?* Dropdown None Yes, attached to wall Yes, free standing
If you own additional properties, please list addresses here* If you own additional properties, please list addresses here*
Additional Information
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 insurance policy?*
Date of Renewal*
Current homeowners 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 insurance* Cost per year for homeowners 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*
Do you own any pets?*
Please list all pets (for dogs please include breed)* Please list all pets (for dogs please include breed)*
List additional RVs, Side-by-Sides, ATVs, Motorcycles, Snowmobiles, etc.
Additional comments, questions, or remarks Additional comments, questions, or remarks
