Spreadsheet: 63975d1264812716-excel-2007-data-validation-issue-personal-lines-quote-sheet1
Sheet: QUOTE

Where did you Hear about Us? | Client Referral |  | Referring Client?
Name
Street Address Location |  |  | (Current Address)
Street Address Mailing
City
State
Zip
County |  |  | (needed for Motorcycle)
Home Phone
Work Phone
Cellphone
[NAME]
Best Way & Time to Reach You?
Agent Notes
Auto Quote
Motorcycle Quote
Home Quote
Dwelling Fire Quote
Umbrella Quote
Watercraft
Life Insurance
AUTO QUOTE
Current Insurance? |  |  | How Long?
Renewal Date |  |  | Annual Premium
Drivers
Driver 1 |  |  | DOB
SSN |  |  | [NAME]. Number
Tickets/Accidents/Claims in 5?
Driver 2 |  |  | DOB
SSN |  |  | [NAME]. Number
Tickets/Accidents/Claims in 5?
Driver 3 |  |  | DOB
SSN |  |  | [NAME]. Number
Tickets/Accidents/Claims in 5?
Driver 4 |  |  | DOB
SSN |  |  | [NAME]. Number
Tickets/Accidents/Claims in 5?
Vehicles
Vehicle 1                         Year |  |  | Make
Model |  |  | VIN
Operator |  |  | Use
Discounts? |  |  | Ownership?
Vehicle 2                         Year |  |  | Make
Model |  |  | VIN
Operator |  |  | Use
Discounts? |  |  | Ownership?
Vehicle 3                            Year |  |  | Make
Model |  |  | VIN
Operator |  |  | Use
Discounts? |  |  | Ownership?
Vehicle 4                         Year |  |  | Make
Model |  |  | VIN
Operator |  |  | Use
Discounts? |  |  | Ownership?
Coverages
Bodily Injury Liability | $15,000 person $30,000 accident
Property Damage Liability | 10000
Tort Option | Limited
[NAME] | $15,000 person $30,000 accident |  | Stacking? | Non-stacked
Underinsured Motorist | $15,000 person $30,000 accident |  | Stacking? | Non-stacked
First Party Medical | 5000
Income Loss | None
Funeral Benefit | None
Accidental Death | None
Extraordinary Medical | None
Vehicles | Collision Ded. |  | Comp Ded | Rental Expense | Towing
 | No Covg |  | No Covg | No Covg | No Covg
 | No Covg |  | No Covg | No Covg | No Covg
 | No Covg |  | No Covg | No Covg | No Covg
 | No Covg |  | No Covg | No Covg | No Covg
Notes
Motorcycle Quote
Zip Code |  |  | County
Prior Insurance? | None |  | Company
Renewal Date |  |  | Premium
Driver 1 |  |  | DOB
SSN |  |  | [NAME]. Number
Tickets/Accidents/Claims in 5? |  |  | [NAME]?
Driver 2 |  |  | DOB
SSN |  |  | [NAME]. Number
Tickets/Accidents/Claims in 5? |  |  | [NAME]?
Driver 3 |  |  | DOB
SSN |  |  | [NAME]. Number
Tickets/Accidents/Claims in 5? |  |  | [NAME]?
Driver 4 |  |  | DOB
SSN |  |  | [NAME]. Number
Tickets/Accidents/Claims in 5? |  |  | [NAME]?
Discounts
Safety Course within 3 years? |  |  | If so, date?
Rider Group Membership? |  |  | HOG, AMA, ABATE, etc
Current Auto Insurance?
Any policies with Farmers?
Homeowner?
Units
Vehicle 1                                 Year |  |  | Make
Model |  |  | Value
Engine [NAME] |  |  | VIN
Additional Value? |  |  | (chrome, saddlebags, etc?)
Collision? |  |  | Comprehensive?
Vehicle 2                                  Year |  |  | Make
Model |  |  | Value
Engine [NAME] |  |  | VIN
Additional Value? |  |  | (chrome, saddlebags, etc?)
Collision? |  |  | Comprehensive?
Vehicle 3                                  Year |  |  | Make
Model |  |  | Value
Engine [NAME] |  |  | VIN
Additional Value? |  |  | (chrome, saddlebags, etc?)
Collision? |  |  | Comprehensive?
Bodily Injury Liability | $15,000 person $30,000 accident
Property Damage Liability | 10000
[NAME] |  |  | Stacking? | Stacked
Underinsured Motorist |  |  | Stacking? | Stacked
First Party Medical | None
Notes
Home Quote
Street Address
City
State
Zip
County
Policy Type?
Occupancy | Primary Residence
Any Claims in Past 5 Yrs ? |  |  | (at this or any other residence)
Current Insurance? |  |  | Annual Premium
Renewal Date
New Purchase Only
Purchase Price |  |  | Mortgage Amount?
Closing Date |  |  | [NAME]?
Mortgage Contact Info
Home Details
Type of Home |  |  | Year Built
Construction |  |  | Square Feet
Exterior Finish
Foundation |  |  | [NAME]? | No
Roof |  |  | Yr Updated?
Heat Type |  |  | Yr Updated?
Electrical to code? |  |  | Yr Updated?
Plumbing to code? |  |  | Yr Updated?
Central Air ?
# [NAME] |  |  | # Baths
[NAME]? (sq ft)
Garage? |  |  | # Cars?
Other Renovations?
Underwriting
Hydrant < 1000' ? |  |  | Fire Dept <5 miles?
Swimming Pool? |  |  | Fenced?
Dogs? |  |  | Breed?
Bite History?
Trampoline?
Own Vacant Land? |  |  | Explain
Own Other Dwellings? |  |  | Explain
Alarm?
Coverages
Dwelling |  |  | Replacement Cost ? | 1.25
Other Structures
Personal Property |  |  | Replacement Cost ? | 1
Loss of Use
Liability | 100000
Med Payments | 1000
Deductible | 500
Water/Sewer Backup | None
Jewelry Rider? |  |  | [NAME]
Firearms Rider? |  |  | [NAME]
Fine Arts Rider |  |  | Other Rider?
Other Endorsements?
Xtend Liability to Other [NAME] ?
Notes
[NAME]
Street Address
City
State
Zip
County
Policy Type | DP3 SPECIAL
Any Claims in Past 5 Yrs ?
Occupancy | Tenant
New Purchase
Purchase Price |  |  | Mortgage Amount?
Closing Date
Current Insurance? |  |  | Annual Premium
Renewal Date
Home Details
Type of Home |  |  | Year Built
Construction |  |  | Square Feet
Exterior Finish
Roof |  |  | Updated?
Heat Type |  |  | Updated?
Electrical |  |  | Updated?
Plumbing |  |  | Updated?
# [NAME] |  |  | # Baths
[NAME]? (sq ft)
Garage? |  |  | # Cars?
Other Renovations?
Hydrant < 1000' ? |  |  | Fire Dept <5 miles?
Swimming Pool? |  |  | Fenced?
Dogs? |  |  | Breed?
Bite History?
Trampoline?
Coverages
Dwelling
Other Structures
Personal Property
Loss of Rents
Liability | 100000
Med Payments | 1000
Deductible | 500
Water/Sewer Backup | None
Notes
Personal Umbrella Quote
Any Liability Claims/Accidents/Violations in past 5 years?
Any additional properties owned?
Any recreational [NAME]?
Business Pursuits?
Limit Desired
Notes
Life Insurance
Insured
Gender |  |  | DOB
Height |  |  | Weight
Nicotine?
Expectant Mother or Father ?
Immediate Relatives w/ Heart Disease?
Immediate Relatives with history of Cancer ?
Cholesterol Level Known?
Check any of the following diagnosed (Past 10 years)
If any of the above, please provide date of onset, diagnosis, and current status
Insured Take any Medications?
If so, list name and dosage
US or Canadian Resident for 12 months?
Term Amount Desired
Term Length Desired
Watercraft
Current Insurance? |  |  | How Long?
Renewal Date |  |  | Annual Premium
Operators
Driver 1 |  |  | DOB
SSN |  |  | [NAME]. Number
Tickets/Accidents/Claims in 5? |  |  | Safety Course?
Yrs Experience on watercraft?
Driver 1 |  |  | DOB
SSN |  |  | [NAME]. Number
Tickets/Accidents/Claims in 5? |  |  | Safety Course?
Yrs Experience on watercraft?
Driver 1 |  |  | DOB
SSN |  |  | [NAME]. Number
Tickets/Accidents/Claims in 5? |  |  | Safety Course?
Yrs Experience on watercraft?
Driver 1 |  |  | DOB
SSN |  |  | [NAME]. Number
Tickets/Accidents/Claims in 5? |  |  | Safety Course?
Yrs Experience on watercraft?
Units
Vehicle 1                         Type |  |  | Make
Model |  |  | Length
Motor Size |  |  | Motor Value
Hull Value |  |  | Hull ID | not req'd for quote
Primary Operator |  |  | Navigable Waters?
Equipment Covg Value? |  |  | Mooring Location?
[NAME] |  |  | Trailer Value
Vehicle 2                         Type |  |  | Make
Model |  |  | Length
Motor Size |  |  | Motor Value
Hull Value |  |  | Hull ID | not req'd for quote
Primary Operator |  |  | Navigable Waters?
Equipment Covg Value? |  |  | Mooring Location?
[NAME] |  |  | Trailer Value
Liability | $15,000 person $30,000 accident
Include watersports Liability?
Uninsured/Underinsured | $15,000 person $30,000 accident
Medical Payments | NONE