Fast App - Agent Entered

Lead Source(Required)

Are You Submitting This to a VA for Quoting?

Yes

Referred By:(Required)

Name Insured(Required)

First Last

Name Insured Gender

Named Insured DOB(Required)

Marital Status

Named Insured Occupation

Named Insured Education

Phone

2nd Named Insured Details

2nd Name Insured (Spouse/Co-Applicant)

First Last

Relationship to Insured

2nd Name Insured Gender

2nd Named Insured DOB

2nd Named Insured Education

Current Address (Required)

Street Address City State ZIP Code

Add Multi-Policy Discounts For:

Auto

Home

Umbrella

Dwelling Fire

RV / ATV

Policies(Required)

click all that apply

Home Details

Is the property location the same as the client's current address?

Yes

No - Use client's current address as the previous address

Effective Date of The New Policy

Is There A Mortgage?

Yes

Insured Property Address(Required)

Street Address City State ZIP Code

Is This A New Purchase?(Required)

Yes

Purchase Price? (Required)

Do You Currently Have Home Insurance?

Yes

Current Home Insurance Company

Are You A First Time Home Buyer

Yes

Date Home Was Purchased

Acreage

Less than 5

More than 5

Inside City Limits

Yes

Photos Are Available Online(Required)

Yes

Limited Availability

Quality of Kitchen(Required)

Builders Grade/Economy

Semi-Custom

Custom

Designer

Luxury

Quality of Bathrooms(Required)

Builders Grade/Economy

Semi-Custom

Custom

Designer

Luxury

Dwelling Type

Year Built

Square Feet

# Stories

Occupancy

Construction Type

Exterior Construction (add. breakdown %'s available below)

Full Bath

Half Bath

Garage

Fireplace

Heating Type

Foundation

Roof Design

Roof Type

Deck or Porch

Yes

Deck or Porch(Required)

Type

Square Ft.

Exterior Construction Additonal Details

Yes

Exterior Construction(Required)

Type

Percentage (Must total 100%)

Flooring(Required)

Type

Percentage (Must total 100%)

Electrical Updates (year)

HVAC Updates (year)

Plumbing Updates (year)

Roof Updates (year)

Coverage

Dwelling Coverage Based On(Required)

Specific Amount

Carrier RCE

Dwelling Coverage Amount

Agent Requests a Copy of the Carrier RCE

Extended Dwelling Coverage(Required)

Liability(Required)

Medical Payments(Required)

Other Structures

Other Structures (Total Value Requested)

All Other Perils (AOP) Deductible(Required)

Water Backup Limit(Required)

Building Ordinance or Law(Required)

Loss Assessment (If part of an HOA)(Required)

Foundation Water Damage(Required)

Yes

Additional Endorsements(Required)

None

Home Cyber Protection

Home System Protection

ID Fraud

Personal Injury

Special Personal Property

Service Line Coverage

Water Back up

Residence Held in a Trust?

Yes

Trust Name

Protective Devices & Discount Questions (click all that apply)

Prior Claims

Yes

Pool/Hot Tub

Yes

Trampoline

Yes

Dogs?

Yes

Prior Claim Details

Include Year and Property Address

How Many?

Pool/Hot Tub (Check All That Apply)

Above Ground

Below Ground

Without a Slide

Without a Diving board

With a Slide

With a Diving Board

Not Fenced

Fenced

Trampoline (Check All That Apply)

Fenced

Netted

Not Fenced

Not Netted

Breed of Dog/s

Bite History?

Yes

Bill Plans(Required)

Notes:

Home File Upload

Drop files here or

Max. file size: 20 MB.

Secondary Home Details

Do You Currently Have Secondary Home Insurance?

Yes

Policy Start Date

Is there a mortgage?

Yes

Current Secondary Home Insurance Company

Is This A New Purchase? (Required)

Yes

Date Home Was Purchased

Purchase Price

Is the Insured Property Address the same as the Mailing Address?

Yes

Optional Policy Level Discounts

E-Signatures

Paperless

Insured Property Address

Street Address City State ZIP Code

Occupancy

Owner Only

Short Term Rental (AirBnB or VRBO)

Is The Property Unoocupied For More Than 8 Consecutive Weeks Per Year?

Yes

Coverages

Dwelling Coverage?

Liability

Medical Payments

Deductibles

Endorsements

Water Backup Limit

Do You Have a Property Manager

Yes

Exterior Construction

Construction Type

Dwelling Type

Occupancy

Year Built

Square Feet

# of Stories

Acreage

Less than 5

More than 5

Full Bath

Half Bath

Garage

Fireplace

Heating Type

Foundation

Roof Design

Roof Type

Electrical Updates (year)

HVAC Updates (year)

Plumbing Updates (year)

Roof Updates (year)

Deck or Porch

Type

Square Ft.

Flooring

Type

Percentage (Must total 100%)

Discount Questions (click all that apply)

Fire Alarm (Monitored 24/7 Central Station)

Fire Alarm (Local)

Burglar Alarm (Monitored 24/7 Central Station)

Burglar Alarm (Local)

Fully Sprinklered Inside

HOA

Guard Gated

Automatic Closing Gate

None

Prior Claims

Yes

Prior Claim Details

Include Year and Property Address

Pool/Hot Tub

Yes

Pool/Hot Tub (Check All That Apply)

Above Ground

Below Ground

Without a Slide

Without a Diving board

With a Slide

With a Diving Board

Not Fenced

Fenced

Trampoline

Yes

Trampoline (Check All That Apply)

Fenced

Netted

Not Fenced

Not Netted

Dogs?

Yes

Number of Dogs

Breed of Dog/s

Bite History

Yes

Notes:

Secondary Home File Upload

Drop files here or

Max. file size: 20 MB.

Renters

Policy Start Date

Optional Policy Level Discounts

E-Signatures

Paperless

Coverages

Personal Property Coverage

Liability

Medical Payments

Deductibles

Notes:

Endorsements

Water Backup

Seepage and Leakage

Sudden and Accidental

Personal Injury

Water Backup Limit

Renters File Upload

Drop files here or

Max. file size: 20 MB.

Condo

Do You Currently Have Condo Insurance?

Yes

Policy Start Date

Is there a mortgage?

Yes

Current Condo Insurance Company

Is This A New Purchase?

Yes

Date Home Was Purchased

Purchase Price

Is the Insured Property Address the same as the Mailing Address?

Yes

Optional Policy Level Discounts

E-Signatures

Paperless

Insured Property Address

Street Address City State ZIP Code

Coverages

Dwelling Coverage

Liability

Medical Payments

Deductibles

Endorsements

Water Backup

Seepage and Leakage

Sudden and Accidental

Personal Injury

Water Backup Limit

Exterior Construction

Construction Type

Occupancy

Year Built

Square Feet

# of Stories

Full Bath

Half Bath

Garage

Fireplace

Heating Type

Foundation

Roof Design

Roof Type

Electrical Updates (year)

HVAC Updates (year)

Plumbing Updates (year)

Roof Updates (year)

Deck or Porch

Type

Square Ft.

Flooring

Type

Percentage (Must total 100%)

Discount Questions (click all that apply)

Fire Alarm (Monitored 24/7 Central Station)

Fire Alarm (Local)

Burglar Alarm (Monitored 24/7 Central Station)

Burglar Alarm (Local)

Fully Sprinklered Inside

HOA

Guard Gated

Automatic Closing Gate

None

Prior Claims

Yes

Prior Claim Details

Include Year and Property Address

Pool/Hot Tub

Yes

Pool/Hot Tub (Check All That Apply)

Above Ground

Below Ground

Without a Slide

Without a Diving board

With a Slide

With a Diving Board

Not Fenced

Fenced

Trampoline

Yes

Trampoline (Check All That Apply)

Fenced

Netted

Not Fenced

Not Netted

Dogs?

Yes

# of Dogs

Breed of Dog/s

Bite History?

Yes

Notes:

Condo File Upload

Drop files here or

Max. file size: 20 MB.

Rental Property/Landlord Details

Rental Property/Landlord Details Entry

Insured Property Address	Actions

There are no Entries.

Please Add Entry to record your Rental Property or Landlord Details

Auto Details

Do You Currently Have Auto Insurance?

Yes

Current Auto Insurance Company

Requested Policy Term(Required)

Policy Start Date

Optional Policy Level Discounts

E-Signatures

Paperless

Billing Plans

Is Named Insured or Spouse a Homeowner?

Yes

Include Multi-Policy Discount?

Yes

Include Named Insured as Driver

Yes

Foreign License

Yes

Named Insured Driver's License #

State/Country

SR22

Yes

Good Student Discount

Yes

Accidents/Violations last 5 years?

Yes

Details of the accident(s) and/or violation(s)

Include 2nd Named Insured as Driver

Yes

Excluded Driver Reason

Foreign License

Yes

2nd Named Insured's Driver's License #

State/Country

SR22

Yes

Good Student Discount

Yes

Accidents/Violations last 5 years?

Yes

Details of the accident(s) and/or violation(s)

Are There Additional Drivers

Yes

Additional Driver Details

Full Name	Date of Birth	Actions

There are no Entries.

Policy Level Coverages

Liability(Required)

Medical Payments

Uninsured/Underinsured Motorist

Property Damage

Vehicle Details

Vehicle Details Entry

VIN #	Vehicle Year	Vehicle Make	Vehicle Model	Actions

There are no Entries.

Please Add Entry to record your Rental Property or Landlord Details

Term Life Insurance

Policy Start Date

Name Insured

First Last

Birthdate

Phone

Married

Yes

Term Length

Desired Amount

Do You Smoke?

Yes

Height

Weight

Pre-existing health conditions?

If yes, details?

Current Life Insurance in force?

Yes

Yes through work

Current Life Insurance Amount?

Current Life Insurance Company?

Life Insurance File Upload

Drop files here or

Max. file size: 20 MB.

Boat

Policy Start Date

Optional Policy Level Discounts

E-Signatures

Paperless

New/Used?

New

Used

Date Purchased

Value

Year

Make

Model

Length

Motor

Horse Power

Hull ID or VIN

Construction Material

Fiberglass, Aluminum, Wood, etc.

Watercraft stored at Home Address

Yes

Watercraft Storage Location

Street Address City State ZIP Code

Year of Boating Experience

Have you completed a Safety Course

Yes

Do you have a trailer to insure

Yes

Year

Make

Model

Value

Trailer ID/Serial #

Any Additional Equipment

Protective Devices

Leased/rented to others

Yes

Used for business

Yes

Previously Salvaged

Yes

Permanent living quarters

Yes

High Performance? (Fast)

Yes

Homemade or Kit

Yes

More than two motors

Yes

Exposed engine, other than outboard

Yes

Corporate owned (Not LLC)

Yes

Do you have a lienhoder

Yes

Lienholder

Boat File Upload

Drop files here or

Max. file size: 20 MB.

RV/Travel Trailer

Policy Start Date

Optional Policy Level Discounts

E-Signatures

Paperless

Address

Street Address City State ZIP Code

Year Purchased?

Actual Cash Value $

Year

Model

Make

VIN#

Length (in ft)

How many slides?

Vehicle Use

How many days per month is it used

RV/Travel Trailer File Upload

Drop files here or

Max. file size: 20 MB.

Motorcycle

Policy Start Date

Optional Policy Level Discounts

E-Signatures

Paperless

Primary Garaging of Bike

Motorcycle Safety Course Date

Year Purchased?

Year

Make

Model

Trike?

VIN#

CC Size

Value

Stock

Yes

Vehicle Use

Annual Miles

Motorcycle Endorsement

Yes

Any Accessories?

Is bike modified? If so, how?

Motorcycle File Upload

Drop files here or

Max. file size: 20 MB.

Mobile Home

Policy Start Date

Optional Policy Level Discount

E-Signatures

Paperless

Insured Property Address(Required)

Street Address City State ZIP Code

Mailing Address(Required)

Street Address City State ZIP Code

Occupancy

Purchase Price

Serial #

Year

Make

Model

Dwelling Coverage Amount

Contents Coverage Amount

Replacement Cost/Actual Cash Value

ACV

Length

Width

In a mobile home park?

Yes

Home Type

Tied Down/Skirted

Tied Down

Skirted

Acres?

Less than 5 Acres

More than 5 Acres

Dogs?

Yes

Breed of Dog/s

Bite History?

Yes

How Many

Mobile Home File Upload

Drop files here or

Max. file size: 20 MB.

Umbrella

Policy Start Date

Coverage Amount(Required)

Number of vehicles to insure

Underlying Auto Liability Limits

Current Auto Carrier

Number of properties to insure

Properties to Insure

Property Type

Underlying Property Liability Limits

Current Carrier

Umbrella File Upload

Drop files here or

Max. file size: 20 MB.

Policy Page Uploads

Auto Declaration

Drop files here or

Max. file size: 20 MB.

Policy Page

Home Declaration

Drop files here or

Max. file size: 20 MB.

Policy Page

Condo Declaration

Drop files here or

Max. file size: 20 MB.

Policy Page

Landlord Declaration

Drop files here or

Max. file size: 20 MB.

Policy Page

Renters Declaration

Drop files here or

Max. file size: 20 MB.

Policy Page

Additional Documents

Drop files here or

Max. file size: 20 MB.

Notes:

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Fast App – Agent Entered