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Please complete the following fields. If you would prefer, you may email or fax copies of your current policy documents such as "declarations" pages or a schedule of benefits. [Click here for contact information]

(* denotes mandatory field)

Name:*
Profession:*
Email:*
Phone:*
Street Address:*
City:*	State:**	Zip:*

You can submit now and be contacted regarding your selections OR you can complete the applicable sections below to receive a pricing indication electronically (requires a valid email address):

Select the types of insurance you are seeking:*

Professional Liability/Malpractice

Select your current or desired limits of liability:

Select your desired policy type: Claims-made Occurrence

Indicate your number of years in private practice/business:

Indicate your current retroactive or prior acts date (claims-made only):

On average, how many hours do you practice/work per week?:

Do you own a practice or business? Yes No

Disability

Occupation/specialty:

Gross Monthly Income (before tax): $

Gender: Male Female

Date of Birth: Year:

Benefit Duration Requested:

Waiting Period/Elimination Period:

Residual Disability Benefits? Yes No

Cost Of Living Adjustment? Yes Yes, 4 year delayed No

Future Increase Option Amount Requested: $

Retirement Contribution Benefit? If so, enter current monthly contribution: $

Business Disability Products

Business/Practice Overhead Expense Disability Insurance

Occupation/specialty:

Gross Monthly Income (before tax): $

Gender: Male Female

Date of Birth: Year:

Benefit Duration Requested:

Waiting Period/Elimination Period:

Fixed Monthly Overhead Amount (excluding owner compensation): $

Life Insurance

Gender: Male Female

Date of Birth: Year:

Height: ft. in.

Weight: lbs.

Do you use tobacco? Yes No

Benefit Amount Desired: $

Term/Duration:

Business Owners Property/General Liability

Business Owners Property/General Liability/Umbrella

Occupation/Industry:

Limits of liability:

Umbrella limit (optional):

Building Construction:

Within 5 miles of a Fire Station? Yes No

Within 1000 ft. of a Fire Hydrant? Yes No

Within 1000 ft. of a commercially navigable body of water? Yes No

Total Building Square Footage:

Square Footage of Your Office:

Replacement Cost Value of all Contents and Build-out of your office: $

Replacement Cost of Building (complete only if you own the entire building): $

Worker's Compensation

Workers Compensation & Employers Liability

Occupation/Industry:

Total Estimated Annual Payroll: $

Total Compensation of Corporate Officers: $

Number of Employees: Full Time Part Time

Long Term Care

Long Term Care Insurance

Gender: Male Female

Date of Birth: Year:

Do you use tobacco? Yes No

Are you married? Yes No

*answer the following questions only if you are married and wish to obtain a pricing indication that includes a cost estimate of Long Term Care Insurance for your spouse as well

Spouse Date of Birth: Year:

Does your spouse use tobacco? Yes No

Medical/Health Insurance

Individual Medical/Health Insurance

Home Zip Code:

Residence County:

Coverage Level:

Client Information:
    Coverage Level:
    Gender: Male Female
    Date of Birth: Year:

Type of Coverage (select all that apply):

HMO
PPO
POS
HSA-compatible
High Deductable

Employee Benefits

Select all that apply:

Health
Dental
Vision
Life
Short-term Disability
Long-term Disability

Does your company currently offer insurance? Yes No

Current carrier and plan types offered:

Current renewal date: Year:

Types of health plans being considered:

HMO
PPO
POS
HSA-compatible
High Deductable

Homeowner/Renter

Social Security Number:

Date of Birth*: Year:

Check here if Residence Address is different from Mailing Address:

Street Address:

City:

State*

Zip:

Check here for quote without ordering insurance score:

Policy Credits Surcharges

Safety Seminar Credit
Green Discount
Deadbolt Credit
Smoke Detector
Fire Extinguisher

24 hr. Security Guard: Yes No

Burglar Alarm Code:

Fire Alarm Code:

Sprinkler Code: Yes No

Feet from Hydrant:

Miles from Fire Department:

Occupancy:

Year Built:

Date Purchased: Year:

Primary Source of Heat:

Primary Community Name:

Responding Fire District:

Number of Stories*:

Number of Mortgages*: 1 2 3

Construction Type*:

Residence Type*: Primary Secondary

Check here if this is a seasonal dwelling:

Number of Units between Fire Walls:

Territory:

Alternative/Supplemental Heat*: Yes No

Roof Type*:

Number of Residence Employees:

Replacement Cost*:

Dwelling Limit:

Liability*:

Medical Payments*:

Deductible*:

Check here if you have had any losses:

Date:

Cause:

Amount of Loss:

Description:

Auto/Car

Automobile/Car

Social Security Number:

Prior Auto Insurance Agency:

Number of Days Lapsed:

Prior Bodily Injury Limits:

Property Damage:

Medical Payments:

Comprehensive Deductible:

Towing:

Uninsured Motorist:

Primary Ownership Status: Home/Condo Rent

Date of Birth*: Year:

Driver Age:

Gender*: Male Female

Marital Status*: Married Single Divorced Widowed

Licence Number:

Licence State*:

Date Licenced if < 4 Years:

Age 1st Licenced*:

Student Operator

Driver Training

Defensive Driver Course Date:

Relationship*:

Operator Insured Elsewhere

UnComp Phys/Med Impairment*: Yes No

MVR Receipt Date:

MVR Response: Yes No

Need to add additional driver?

Social Security Number:

Prior Auto Insurance Agency:

Number of Days Lapsed:

Prior Bodily Injury Limits:

Property Damage:

Medical Payments:

Comprehensive Deductible:

Towing:

Uninsured Motorist:

Primary Ownership Status: Home/Condo Rent

Date of Birth*: Year:

Driver Age:

Gender*: Male Female

Marital Status*: Married Single Divorced Widowed

Licence Number:

Licence State*:

Date Licenced if < 4 Years:

Age 1st Licenced*:

Student Operator

Driver Training

Defensive Driver Course Date:

Relationship*:

Operator Insured Elsewhere

UnComp Phys/Med Impairment*: Yes No

MVR Reciept Date:

MVR Response: Yes No

Vehicle Make*:

Vehicle Model*:

Vehicle Year*:

Daytime Running Lights
Anti-Lock Brakes
Vehicle Used for Commute
Farm Use
Business Use
Customization
Racing Equipment
Broken/Cracked Glass
Cost New

Lienholder on Vehicle*: Yes No

Performance:

Rating City:

Rating County:

Need to add another car?

Vehicle Make:

Vehicle Model:

Vehicle Year:

Who is Vehicle Operated by:

Primary Use of Vehicle:

Approx. number of miles driven each year:

Please describe any incidents/accidents:

Motorcycle

Social Security Number:

Rent or Own Your Home: Home/Condo Rent

Motorcycle Information

Make*:

Licensed for Road Use: Yes No

Model or Model #*:

Model Year*:

Cycle Purchase Date:

# of CCs:

VIN#:

Current Value:

Purchased new or used: New Used

Value of Optional Equipment (if any):

Describe Customizations (if any):

Audible Alarm: Yes No

Cycle Stored At Night:

Is there a Lienholder/Leaseholder: Yes No Not Sure

Name of lienholder (if applicable):

Comprehensive Deductible Desired:

Collision Deductible Desired:

Current Insurance Policy Details

Do you presently have motorcycle insurance: Yes No

If so, what company is it with:

How long have you had this policy:

Gender*: Male Female

Date of Birth*: Year:

Current Age:

Marital Status*: Married Single Divorced Widowed

Motorcycle Tag Number:

What State Issued Your Motorcycle Tag*:

Driver's License Number:

What State Issued Your Driver's License:

License suspended, canceled or revoked (last 5 years): Yes No

Annual Mileage:

Daily Commute Mileage (one way):

Do you allow passengers on your motorcycle? Yes No

Rider Experience:

Always Wear Helmet? Yes No

Tickets (last 3 years):

Accidents (last 3 years):

Rider Safety Course Class? Yes No

Tickets and Accidents (last 5 years):

Other Drivers

Please provide the names and birthdates of any other motorcycle drivers in your home.

Other Driver 1

Name:

Date of Birth*: Year:

Drivers Licence Number:

Relationship:

Tickets and Accidents (last 5 years):

Other Driver 2:

Name:

Date of Birth*: Year:

Drivers Licence Number:

Relationship:

Tickets and Accidents (last 5 years):

Comments/Additional Information:

Boat/Yacht

Social Security Number:

Boat Owner Information

Relationship to Applicant:

Name on Driver's License:

Driver's License Number:

Date of Birth*: Year:

Current Age:

License State:

Gender*: Male Female

Marital Status*: Married Single Divorced Widowed

Years Boating Experience:

Years Owned This Boat:

Claims (last 5 years):

Boating Courses/Licenses (provide details):

Prior Boats Owned (Type, Size, Years Owned)

Most Recent:

Previous 1:

Previous 2:

Previous 3:

Vessel Information

Purchase Price*:

Date Of Survey (if available):

Hull Power*: Sail Power

Hull ID#:

Make*:

Year*:

Model*:

Top Speed*:

Total Horsepower*:

Year Purchased*:

Length*:

Construction*:

Equipment & Usage

Engine Specifics:

How Many Engines*:

Engine Type*:

Engine Fuel Type*:

Engine Count:

Engine Make*:

Engine Year*:

Engine Model*:

Engine HP:

Engine Serial Numbers

Engine 1 Serial Number:
Engine 2 Serial Number:
Engine 3 Serial Number:
Engine 4 Serial Number:

Vessel Equipment (check all that apply)

EPIRB
Depth Finder
Fume Detector
VHF
Radar
Automatic Halon/CO2
GPS
Loran
Navigation Software

Other Equipment:

Vessel Use

Type of Use:

Navigation Area/Local:

Mooring Location:

If laid up part of the year, from: to:

Laid Up Where:

Coverages Desired

Please provide the following of any other residents in your household licensed to drive:

Hull and Machinery Limit:

Deductible:

P&I Liability Limit:

Current Insurance Company:

Expiration Date:

Current Premium:

Other:

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Professional Liability/Malpractice

Disability

Business/Practice Overhead Expense Disability Insurance

Life Insurance

Business Owners Property/General Liability/Umbrella

Workers Compensation & Employers Liability

Long Term Care Insurance

Individual Medical/Health Insurance

Employee Benefits

Homeowner/Renter

Automobile/Car

Motorcycle

Boat/Yacht