ALLCHOICE Insurance
Quote – Internal – Call Out
Quote – Internal – Call Out
Who is completing this form?
*
ALLCHOICE Team Member
Deserae Harley
Heromi Del Rosario
Laine Fowler
AJ Brower
Heather Bailey
Jared Bellmund
Jack Wingate
Cheyenne Mathews
John Surigao
Sara Surigao
Ed Johnson
Mike Reese
Paul Shockley
Which Agent Do You Want To Work With?
Not Specified
AJ Brower
Heather Bailey
Cheyenne Mathews
Sara Surigao
John Surigao
Ed Johnson
Mike Reese
Jared Bellmund
Jack Wingate
Jeff Hall
Bill Heasley
Enter Agent Email If You Want The Agent To Receive Notification
WHAT IS IMPORTANT TO THE CLIENT?
Before We Get Started, Let Us Know What Is Important To You When It Comes To Your Insurance
(Other Than Price) What Is Most Important When It Comes To Choosing An Insurance Carrier?
*
Claims Service
Financial Rating
Steady Pricing (Limited Price Spikes Up Or Down)
(Other Than Price) What Is Most Important When It Comes To Choosing An Insurance Advisor?
*
An Advisor That Will Educate Me About My Coverages & Offer Advice
Positive Reviews (ex Google Review)
Anywhere Access (Online, Text, Phone, etc)
Access To Multiple Insurance Carriers
Quick Turnaround On Service Requests
INSURED | CONTACT INFORMATION
Insured Name
*
First
Last
Business Name (If Business Risk)
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mobile Phone
*
Is It OK To Text You?
*
Yes
No
Email
LEAD TYPE | LINES OF BUSINESS
What Type Of Insurance Are You Looking For?
Personal
Business
Gender
Male
Female
Date Of Birth
Social Security Number
**We can get preliminary pricing without your social, but we will need this information for final pricing**
Driver's License Number
Federal ID
Marital Status
Single
Married
Civil Union
Spouse | Partner Name
First
Last
Spouse/Partner Gender
Male
Female
Spouse/Partner Date Of Birth
Spouse/Partner Social Security Number
Spouse/Partner Driver's License Number
Description Of Business (What Do You Do?)
Years In Business
Annual Revenue (If New Business = 12 Months Projected)
Number Of Employees
Annual Payroll (If New Business = 12 Months Projected)
POLICY | QUOTE INFORMATION
Personal Policy Type(s)
AUTOP
HOME
PUMBR
RENTAL PROPERTY
What type of insurance can we help you with
Is This A Trucking Exposure?
No
Yes
Department Of Transportation Number (DOT #)
Motor Carrier Number (MC#)
Business Policy Type(s)
AUTOB
BOP/CPKGE
WORK
CUMBR
HABITATIONAL
What type of insurance can we help you with
Personal Auto Policy Information
Current Coverage
Yes
No
Do you have current insurance coverage?
Current Carrier
Who is your current carrier?
Effective Date
MM slash DD slash YYYY
Bodily Injury Liability
$250,000 | $500,000
$100,000 | $300,000
$50,000 | $100,000
$30,000 | $60,000
Property Damage
$100,000
$50,000
$250,000
$25,000
Medical Payment
None
$1,000
$2,000
$5,000
$10,000
Driver Information
Number of Drivers (Other than Insured & Spouse / Partner)
1
2
3
Personal Driver 1
First
Last
Date of Birth (Driver 1)
Driver's License Number (Driver 1)
Personal Driver 2
First
Last
Date of Birth (Driver 2)
Driver's License Number (Driver 2)
Personal Driver 3
First
Last
Date of Birth (Driver 3)
Driver's License Number (Driver 3)
Personal Vehicle Information & Vehicle Level Coverage
Number of Vehicles
1
2
3
4
Vehicle 1 Year
Vehicle 1 Make
Vehicle 1 Model
Vehicle 1 VIN
Other Than Collision | Comprehensive Coverage
No Coverage
$0 Deductible
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Collision Coverage
No Coverage
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Rental Reimbursement / Extended Transportation
No Coverage
$15 Day / $450 Max
$30 Day / $900 Max
$50 / $1,500
Road Service / Towing & Labor
No Coverage
$25
$50
$100
Vehicle 2 Year
Vehicle 2 Make
Vehicle 2 Model
Vehicle 2 VIN
Other Than Collision | Comprehensive Coverage
No Coverage
$0 Deductible
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Collision Coverage
No Coverage
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Rental Reimbursement / Extended Transportation
No Coverage
$15 Day / $450 Max
$30 Day / $900 Max
$50 / $1,500
Road Service / Towing & Labor
No Coverage
$25
$50
$100
Vehicle 3 Year
Vehicle 3 Make
Vehicle 3 Model
Vehicle 3 VIN
Other Than Collision | Comprehensive Coverage
No Coverage
$0 Deductible
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Collision Coverage
No Coverage
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Rental Reimbursement / Extended Transportation
No Coverage
$15 Day / $450 Max
$30 Day / $900 Max
$50 / $1,500
Road Service / Towing & Labor
No Coverage
$25
$50
$100
Vehicle 4 Year
Vehicle 4 Make
Vehicle 4 Model
Vehicle 4 VIN
Other Than Collision | Comprehensive Coverage
No Coverage
$0 Deductible
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Collision Coverage
No Coverage
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Rental Reimbursement / Extended Transportation
No Coverage
$15 Day / $450 Max
$30 Day / $900 Max
$50 / $1,500
Road Service / Towing & Labor
No Coverage
$25
$50
$100
Enter Misc Auto Information
Upload Any Auto Insurance Files You May Have
Drop files here or
Select files
Max. file size: 12 GB.
Business Auto Policy Information
Current Commercial Auto Coverage
*
Yes
No
Do you have current insurance coverage?
Current Carrier
Who is your current carrier?
Effective Date
MM slash DD slash YYYY
Combined Single Limit
$1,000,000
$750,000
$500,000
$300,000
UnInsured/UnderInsured Combined Single Limit
$1,000,000
$750,000
$500,000
$300,000
Medical Payment
$5,000
$1,000
$2,000
$10,000
None
Additional Policy Level Coverage(s)
Hired Auto
Non-Owned Auto
Commercial Driver Information
Number of Commercial Drivers
1
2
3
4
Commercial Driver 1
First
Last
Date of Birth (CD 1)
Driver's License Number (CD 1)
Commercial Driver 2
First
Last
Date of Birth (CD 2)
Driver's License Number (CD 2)
Commercial Driver 3
First
Last
Date of Birth (CD 3)
Driver's License Number (CD 3)
Commercial Driver 4
First
Last
Date of Birth (CD 4)
Driver's License Number (CD 4)
Vehicle Information & Vehicle Level Coverage
Number of Commercial Vehicles
1
2
3
4
Vehicle 1 Year
Vehicle 1 Make
Vehicle 1 Model
Vehicle 1 VIN
Vehicle 1 Original Cost New
Vehicle 1 Stated Value
Vehicle 1 GVW
Radius Of Operations
Other Than Collision | Comprehensive Coverage
No Coverage
$0 Deductible
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Collision Coverage
No Coverage
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Rental Reimbursement / Extended Transportation
No Coverage
$15 Day / $450 Max
$30 Day / $900 Max
$50 / $1,500
Road Service / Towing & Labor
No Coverage
$25
$50
$100
Vehicle 2 Year
Vehicle 2 Make
Vehicle 2 Model
Vehicle 2 VIN
Vehicle 2 Original Cost New
Vehicle 2 Stated Value
Vehicle 2 GVW
Radius Of Operations
Other Than Collision | Comprehensive Coverage
No Coverage
$0 Deductible
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Collision Coverage
No Coverage
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Rental Reimbursement / Extended Transportation
No Coverage
$15 Day / $450 Max
$30 Day / $900 Max
$50 / $1,500
Road Service / Towing & Labor
No Coverage
$25
$50
$100
Vehicle 3 Year
Vehicle 3 Make
Vehicle 3 Model
Vehicle 3 VIN
Vehicle 3 Original Cost New
Vehicle 3 Stated Value
Vehicle 3 GVW
Radius Of Operations
Other Than Collision | Comprehensive Coverage
No Coverage
$0 Deductible
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Collision Coverage
No Coverage
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Rental Reimbursement / Extended Transportation
No Coverage
$15 Day / $450 Max
$30 Day / $900 Max
$50 / $1,500
Road Service / Towing & Labor
No Coverage
$25
$50
$100
Vehicle 4 Year
Vehicle 4 Make
Vehicle 4 Model
Vehicle 4 VIN
Vehicle 4 Original Cost New
Vehicle 4 Stated Value
Vehicle 4 GVW
Radius Of Operations
Other Than Collision | Comprehensive Coverage
No Coverage
$0 Deductible
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Collision Coverage
No Coverage
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
Rental Reimbursement / Extended Transportation
No Coverage
$15 Day / $450 Max
$30 Day / $900 Max
$50 / $1,500
Road Service / Towing & Labor
No Coverage
$25
$50
$100
Enter Misc Auto Information
Upload Any Auto Insurance Files You May Have
Drop files here or
Select files
Max. file size: 12 GB.
Trucking Related Coverages
Do You Need Trailer Interchange Coverage?
No
Yes
Do You Need Primary Liability Coverage?
No
Yes
Do You Need Non-Trucking Liability (Bobtail)?
No
Yes
Do You Need Cargo Coverage?
No
Yes
How Much Cargo Coverage Do You Need?
Do You Need Reefer Coverage?
No
Yes
How Many Types Of Goods Are Hauled?
1
2
3
4
Type Of Goods – Description
Percentage Of Total Goods
Type Of Goods – Description
Percentage Of Total Goods
Type Of Goods – Description
Percentage Of Total Goods
Type Of Goods – Description
Percentage Of Total Goods
Home Information
New Purchase Or Existing Home
New Home Purchase
Existing Home
Closing Date
MM slash DD slash YYYY
Loan Officer Name
First
Last
Loan Officer Email
Loan Officer Mobile Phone
Realtor Name
First
Last
Realtor Email
Realtor Mobile Phone
Closing Attorney Name
First
Last
Closing Attorney Email
Closing Attorney Mobile Phone
Previous Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Effective Date
MM slash DD slash YYYY
Current Carrier
Purchase Price
What Type Of Home?
Single Family
Townhome
Condo
Manufactured Home
Double Wide
Single Wide
Home Occupany?
Primary Residence
Secondary Or Seasonal Residence
Rented To Others
Does The HOA Cover The Shell?
Yes
No
New Construction
Yes
No
Year Built
Is House Older Than 20 Years
Yes
No
If House Older Than 20 Years – Year Of Roof Update
If House Older Than 20 Years – Year Of Electric Update
If House Older Than 20 Years – Year Of Plumbing Update
If House Older Than 20 Years – Year Of HVAC Update
Construction Of Home
Frame
Brick Veneer
Log
Other
Square Footage
Number Of Stories
Dimensions
Please enter in Feet (ex 20ft X 60ft)
Foundation Type
Slab
Crawl Space
Basement – Unfinished
Basement – Partial Finish
Basement – Finished
Elevated
Homeowner's Coverage Information
Dwelling Coverage Amount
Deductible
$1,000
$1,500
$2,500
$5,000
Personal Liability
$1,000,000
$500,000
$300,000
Medical Payments To Others
$1,000
$2,000
$5,000
Enter Misc Homeowner's Info
Upload Any Homeowner's Files You May Have
Drop files here or
Select files
Max. file size: 12 GB.
Business Owners Information
Effective Date
MM slash DD slash YYYY
Current Coverage
Yes
No
Current Carrier
BOP Coverage Types
General Liability Only (GL)
GL + Building Coverage
GL + Business Contents
GL + Building + Business Contents
Number of Location(s)/Building(s)
Same As Mailing Addres
Main Address (Other Than Mailing)
Add’l Locations (Other Than Primary)
Enter # of Locations/Buildings (if more than 2 please enter information in “Multiple Location | Building Info” Section
Primary Location Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Multiple Location | Building Info
Enter Any Address Info | Coverage Info as notes
Business Owners Coverage Information
General Liability Limits
$1,000,000 | $2,000,000
$500,000 | $1,000,000
$300,000 | $600,000
Building Coverage
Business Personal Property Coverage
Optional Coverage (Select All That Apply)
Cyber Liability
Employment Practices Liability
Professional Liability
Enter Misc BOP | CPKG Info
Upload Any BOP | CPKG Files
Drop files here or
Select files
Max. file size: 12 GB.
Workers Compensation Information
Effective Date
MM slash DD slash YYYY
Current Coverage
Yes
No
Current Carrier
Number Of Class Codes
1
2
3
Class Code (Main)
If you don’t have/know the Code – please enter description
Class Code Payroll (Main)
Class Code (2)
If you don’t have/know the Code – please enter description
Class Code Payroll (2)
Class Code (3)
If you don’t have/know the Code – please enter description
Class Code Payroll (3)
Workers Compensation Coverage Information
Workers Compensation Limit
$1,000,000 | $1,000,000 | $1,000,000
$500,000 | $500,000 | $500,000
$100,000 | $500,000 | $100,000
Enter Misc Workers Compensation Information
Upload Misc Workers Compensation Files
Drop files here or
Select files
Max. file size: 12 GB.
Personal Umbrella Coverage
Effective Date
MM slash DD slash YYYY
Current Coverage
Yes
No
Current Carrier
Personal Umbrella Limit
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
$7,000,000
$8,000,000
$9,000,000
$10,000,000
Enter Misc Personal Umbrella Information
Enter any misc info (ex. Underlying Coverage(s) and rating info not already entered)
Upload Personal Umbrella Files
Drop files here or
Select files
Max. file size: 12 GB.
Commercial Umbrella Coverage
Effective Date
MM slash DD slash YYYY
Current Coverage
Yes
No
Current Carrier
Commercial Umbrella Limit
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
$7,000,000
$8,000,000
$9,000,000
$10,000,000
Enter Misc Commercial Umbrella Information
Enter any misc info (ex. Underlying Coverage(s) and rating info not already entered)
Habitational | Rental Property Information
Effective Date
MM slash DD slash YYYY
Current Coverage
Yes
No
Current Carrier
Habitational | Rental Property Coverage
Number of Location(s) | Building(s)
1
More Than 1
If More than 1 location or building – please enter information in “Enter More Location Information” Section or upload current Dec Pages in the Upload File Section
Location Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Building Coverage
Year Built
Square Footage
Number of Families Per Building
1 (Single Family)
2 (Duplex)
3
4
5-10
11-20
20+
Construction
Frame
Masonry Veneer
Joisted Masonry
Masonry Non-Combustible
Non-Combustible
Number of Stories
1
2
3
4
5+
Sprinklered
Yes
No
Enter More Location Information
Enter Misc Habitational | Rental Property Information
Upload Habitational | Rental Property Files
Drop files here or
Select files
Max. file size: 12 GB.
Upload Bond | Surety Misc Files
Drop files here or
Select files
Max. file size: 12 GB.
Lead Source [Producer Completed]
How did the prospect became aware of ALLCHOICE Insurance? Did they learn about ALLCHOICE through Agent Activity? (Agent Activity) Was it through a referral from someone they know? (Referral) Or are they already a Current Client of ALLCHOICE Insurance? (Current Client)"
*
Agent Activity
Referral
Current Client
Agent Activity – Lead Source
Provide details about the agent's interaction with prospect?
*
Referral – Lead Source
Who referred prospect to ALLCHOICE Insurance?
*
Current Client – Lead Source
What motivated client to revisit our services or seek additional assistance?
*
Disclosure Statement
By submitting this request, you agree to receive communication(s) from ALLCHOICE, Inc. via Phone, Text, SMS, Email, Voicemail, or any other form of communication that may be deemed as beneficial.
We use the information you provide as well as information from other sources, such as your driving record, claims, and credit histories, to calculate a price for your insurance.
Confirmation
Please review your information to ensure all fields are filled before submitting.
*
I confirm that all the information provided above is accurate and complete.
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