Request ConsultationStep 1 of 224%Assigned AdvisorAmanda ChenApril HolmesGerald ShopeTyson ClarkHow did you hear about us?Client ReferralGoogleFacebookMortgage ReferralRealtor ReferralOtherWho Referred You?What type of insurance can we quote for you?(Required) Auto Home Condo Umbrella Investment Property Motorcycle/Slingshot/ATV Golf Cart Boat RV OtherWhat other type of insurance can we quote for you?(Required)New purchase or already own the condo/home?(Required) New Purchase Already OwnHow do you use the condo?(Required) Primary Residence Secondary Residence RentalName(Required) First Last Phone(Required)Email(Required) Date of Birth MM slash DD slash YYYY Drivers LicenseSSNOccupationMarital Status Single Married Divorced WidowedSpouse InformationSpouse will be considered driver #2 if quoting auto.Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY SSNPhoneCurrent Address (location of home to be insured)(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Current CountyYears At Current AddressMailing address different than location address? Yes NoMailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Years at current address0-2 Years2-5 Years5+ YearsPrior Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Purchase Date/Closing Date MM slash DD slash YYYY Year Home Was BuiltProperty TypeSingle FamilyMulti FamilyCondoFarm/RanchMobile HomeVacant LandSq FtFoundationBasementCrawlspaceSlabFinished Basement %Frame DetailVinylMetalHardiplankWoodBrick VeneerStone Veneer# of stories 1 1.5 2Bathrooms11.522.533.544.5Roof MaterialComposite ShinglesAsphalt ShinglesArchitectural ShinglesMetalTileRoof ShapeHipGableFlatYear Roof UpdatedAny updates to heating, electrical or plumbing? Heating Electrical PlumbingYear Heating UpdatedType of Update Full Replacement Partial UpdateYear Electrical UpdatedType of Update Full Replacement Partial UpdateYear Plumbing Updated?Type of Update Full Replacement Partial UpdateGarage Yes Attached Yes Detached NoneGarage 1 Car 2 Car 3 Car 4 CarDetached Structures Yes NoDetatched StructureYear Built open boxWhat Type?GarageShopShedBarnPool HouseOtherWhat Type?(Required)Detached Structure Sq. FootageDetatched Building ExteriorWoodMetalVinylOtherOther Exterior MaterialDetatched Roof TypeAsphalt ShingleMetalOtherOther Roof Type(Required)Detatched Building Roof AgeDetached Structures Used For Farming Purposes? Yes NoWhich building and how is it used?(Required)More than 5 acres? Yes NoFireplace Yes - Gas Yes - Wood NoWoodstove Yes NoDeck/Patio Yes - Covered Yes - Screened Yes - Enclosed NoSq. FootageSwimming Pool(Required) Yes NoSwimming Pool Fenced and Locked?(Required) Yes NoDiving Board or Slide?(Required) Yes NoTrampoline(Required) Yes NoTrampoline Has A Net?(Required) Yes NoMonitored Burglar/Fire Alarm?(Required) Yes NoAlarm CompanyResponding Fire Department?Miles to Fire Department?Paid Fire Subscription Required? Yes No UnknownFire Protection ClassAny Pets? Cat Dog Cat & Dog OtherDog Breeds Add RemoveIf mixed please indicate type of mix.Any bite history or security training?(Required) Yes NoAny Horses? Yes NoHow Many?(Required)Any Cattle? Yes NoHow Many?(Required)Any Other Livestock? Yes NoTypes of LivestockLivestockHow Many Add RemoveFarming Operations? Yes NoScheduled Personal Property Jewelry Furs Firearms Art Cameras Musical Instruments OtherTotal Value of Jewelry Owned?Total Value of Firearms Owned?Total Value of Art/Cameras/Furs/Musical Instruments Owned?Valuable Items List (Click the + to add additional items) Add RemovePlease list each item and include an appraised/estimated value. Only one item per row please.Home NotesFarmingFarming TypeAnnual Farming IncomeCurrent Carrier InformationCurrent CarrierPolicy Expiration MM slash DD slash YYYY Dwelling LimitPersonal Property LimitLiability LimitDeductibleCurrent PremiumEscrowed Yes NoMortgage CompanyHave there been any home claims in the last 5 years? Yes NoClaims Add RemoveInclude Date of claim, Type of claim (wind/hail/water/lightning/other), Amount paid.Total Drivers in Home(Required) 1 2 3 4 5Total Vehicles in Home(Required) 1 2 3 4 5Med PayVehicle #1Vehicle YearMakeModelVINComprehensive Deductible $500 $1,000 Decline CompCollision Deductible $500 $1,000 Decline CompBusiness Use Yes NoRideshare or Delivery?(Required) Yes NoRoadside Yes NoRental Reimbursement Yes NoVehicle #2Vehicle YearVehicle MakeVehicle ModelVINComprehensive Deductible $500 $1,000 Decline CompCollision Deductible $500 $1,000 Decline CompBusiness Use(Required) Yes NoRideshare or Delivery(Required) Yes NoRoadside Yes NoRental Reimbursement Yes NoVehicle #3Vehicle YearVehicle MakeVehicle ModelVINBusiness Use Yes NoRideshare or Delivery(Required) Yes NoRental Reimbursement Yes NoRental Reimbursement $30/Day $50/DayComprehensive Deductible $500 $1,000 Decline CompCollision Deductible $500 $1,000 Decline CompVehicle #4Vehicle YearVehicle MakeVehicle ModelVINBusiness Use Yes NoRideshare or Delivery(Required) Yes NoRental Reimbursement Yes NoRental Reimbursement $30/Day $50/DayComprehensive Deductible $500 $1,000 Decline CompCollision Deductible $500 $1,000 Decline CompVehicle #5Vehicle YearVehicle MakeVehicle ModelVINBusiness Use Yes NoRideshare or Delivery(Required) Yes NoRental Reimbursement Yes NoRental Reimbursement $30/Day $50/DayComprehensive Deductible $500 $1,000 Decline CompCollison Deductible $500 $1,000 Decline CompDriver #2Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY SSNDrivers LicenseRelationship to you(Required) Spouse Child Parent OtherOccupationAny tickets or accidents in the last 5 years?DateDescription Add RemoveDriver #3Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY SSNDrivers LicenseRelationship to you(Required) Spouse Child Parent OtherOccupationAny tickets or accidents in the last 5 years?DateDescription Add RemoveDriver #4Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY SSNDrivers LicenseRelationship to you(Required) Spouse Child Parent OtherOccupationAny tickets or accidents in the last 5 years?DateDescription Add RemoveDriver #5Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY SSNDrivers LicenseRelationship to you(Required) Spouse Child Parent OtherOccupationAny tickets or accidents in the last 5 years?DateDescription Add RemoveCurrent Auto Policy InformationLiability Limits $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 $500,000/$500,000/$500,000UM/UIM $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 DeclineCurrent Auto Insurer Name First Last Current Policy Expiration Date MM slash DD slash YYYY Length of Time with Current Auto InsurerCurrent Towing Limit?Current Rental Car Reimbursement Limit? Current Monthly Auto PremiumPay Plan PreferredFull Pay2 Pay4 PayMonthly Dwelling Fire PolicyAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Property Status(Required) Currently Occupied with Tenants Listed For Sale - No Occupants Listed For Rent - No Occupants Undergoing Renovations - VacantUntitled First Choice Second Choice Third ChoiceMotorcycle/ATVName of Primary Driver(Required) First Last Vehicle Type(Required) Motorcycle Slingshot ATVIs Vehicle Used for Racing?(Required) Yes NoCurrent Motorcycle License Yes NoHas Driver Completed Safety Course? Yes NoYearMakeModelVINUmbrellaIn order to purchase an umbrella liability policy you must have auto liability limits of at least $250,000/$500,000/$250,000 and home/renters liability of at least $300,000.(Required) I understand that if the current liability limits on my auto and home/renters policies do not meet those minimums I will not be eligible to purchase an umbrella liability policy.How many homes do you own?(Required)This includes primary, secondary, vacation, rental and investment properties.How many home/renters claims have you made in the last 5 years?(Required)How many vehicles do you own?(Required)Do you own any of the following items?(Required) Boat/Yacht Motorcycle ATV Golf Cart Vacant Land BusinessBoat InformationWhere is boat stored? Primary Residence Marina - Slip OtherYearMakeModelHull NumberMotor Type Inboard OutboardTop Speed (MPH)Boat LengthBoat is used for racing? Yes NoDo you own a boat trailer? Yes NoGolf CartYearMakeModelPrimary Use Transportation GolfingFuel Type Electric GasRecreational VehicleRV Type 5th Wheel Motorcoach OtherYearMakeModelPlease upload current policy documents if you have them available.Max. file size: 1 GB.Consent(Required) Clear View Insurance Specialists may contact me via phone call, email and text message.I agree to the Clear View Insurance Specialists privacy policy and I give them permission to contact me by phone, email and text message.Notes - Comments - DetailsCAPTCHA
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