ALLCHOICE Insurance
Quote – Internal – Call In
Quote – Internal – Call In
Who is completing this form?
(Required)
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
WHAT IS IMPORTANT TO YOU?
(Other Than Price) What Is Most Important When It Comes To Choosing An Insurance Carrier?
(Required)
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?
(Required)
An Advisor That Will Educate Me About My Coverages & Offer Advice
Positive Reviews (Ex. Google Reviews)
Anywhere Access (Online, Text, Phone, etc)
Access To Multiple Insurance Carriers
Quick Turnaround On Service Requests
PLEASE SELECT THE TYPE OF INSURANCE YOU NEED
What Type Of Insurance Are You Looking For?
(Required)
Personal
Business
Personal = Home, Auto, Umbrella Insurance Business = Business For A Business
INSURED | CONTACT INFORMATION
Insured Name | Main Contact
(Required)
First
Last
Business Name
(Required)
Address
(Required)
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
(Required)
Is It OK To Text You?
(Required)
Yes
No
Email
(Required)
Gender
Male
Female
Date Of Birth
Social Security Number
This is an Insurance Pull, which is a “soft pull” on their credit
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?)
Does The Company Have A Website
No
Yes
Company Website
Years In Business
Annual Revenue (If New Business = 12 Months Projected)
Number Of Employees
Annual Payroll (If New Business = 12 Months Projected)
PLEASE SELECT THE TYPE(S) OF INSURANCE YOU WANT
Personal Policy Type(s)
(Required)
Personal Auto
Homeowners (Includes Condo & Townhome)
Personal Umbrella
Renters Insurance
Rental Property
Business Policy Type(s)
(Required)
Business Auto
Business Owners (General Liability)
Workers Compensation
Commercial Umbrella
Habitational (Rentals Or Apartments)
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.
Personal Auto Policy Information
Current Personal Auto Coverage Coverage
(Required)
Yes
No
Do you have current insurance coverage?
Current Carrier
Who is your current carrier?
Effective Date
(Required)
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
(Required)
Yes
No
Do you have current insurance coverage?
Current Carrier
Who is your current carrier?
Effective Date
(Required)
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.
Home Information
New Purchase Or Existing Home
(Required)
New Home Purchase
Existing Home
Closing Date
(Required)
MM slash DD slash YYYY
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
(Required)
MM slash DD slash YYYY
Current Home Carrier
Purchase Price
What Type Of Home?
Single Family
Townhome
Condo
Home Occupancy?
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
If House Older Than 20 Years – Year Hot Water Heater Replaced
Construction Of Home
Frame
Brick Veneer
Log
Other
Square Footage
Number Of Stories
Foundation Type
Slab
Crawl Space
Basement – Unfinished
Basement – Partial Finish
Basement – Finished
Elevated
Are there animals, including farm animals or pets on the premises?
Yes
No
Provide Animal Type(s) (If Dog include breed) (are any animals dangerous or show propensity to bite)
Homeowner's Coverage Information
Dwelling Coverage Amount
Deductible
$1,000
$1,500
$2,500 (Recommended)
$5,000
Personal Liability
$1,000,000 (Recommended)
$500,000
Medical Payments To Others
$1,000
$2,000
$5,000 (Recommended)
Enter Misc Homeowner's Info
Upload Any Homeowner's Files You May Have
Drop files here or
Select files
Max. file size: 12 GB.
Renters Insurance
Have You Lived At The Current Address More Than 1 Year?
Yes
No
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
(Required)
MM slash DD slash YYYY
Contents Coverage Amount (This Covers Your "Stuff")
$12,000 Minimum
Deductible
$1,000
$1,500
$2,500
$5,000
Personal Liability
$1,000,000 (Recommended)
$500,000
Medical Payments To Others
$1,000
$2,000
$5,000 (Recommended)
Are there animals, including farm animals or pets on the premises?
Yes
No
Provide Animal Type(s) (If Dog include breed) (are any animals dangerous or show propensity to bite)
Business Owners Information
Effective Date
(Required)
MM slash DD slash YYYY
Current Business Owners Or GL Coverage
(Required)
Yes
No
Current Carrier
Business Coverage Types
(Required)
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
Building Coverage
Business Personal Property Coverage
Optional Coverage (Select All That Apply)
Cyber Liability
Employment Practices Liability
Professional Liability
Enter Misc Business Insurance Notes
Upload Any BOP | CPKG Files
Drop files here or
Select files
Max. file size: 12 GB.
Workers Compensation Information
Effective Date
(Required)
MM slash DD slash YYYY
Current Work Comp Coverage
(Required)
Yes
No
Current Carrier
Do You Know Your Workers Compensation Class Code(s)?
No
Yes
How Many Class Codes Do You Have?
1
2
3
Class Code (Main)
Class Code Payroll (Main)
Class Code (2)
Class Code Payroll (2)
Class Code (3)
Class Code Payroll (3)
Workers Compensation Coverage Information
Workers Compensation Limit
$1,000,000 | $1,000,000 | $1,000,000 (Recommended)
$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
(Required)
MM slash DD slash YYYY
Current Personal Umbrella Coverage
(Required)
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
**Please Note – Your Umbrella Limit Should Be Equal To (Or Greater Than) Your Total Asset Value
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
(Required)
MM slash DD slash YYYY
Current Commercial Umbrella Coverage
(Required)
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
(Required)
MM slash DD slash YYYY
Current Habitational Or Rental Property Coverage
(Required)
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.
How Did You Find ALLCHOICE Insurance?
To better serve you and others, we're curious about the channels through which you found us. Did you come across ALLCHOICE Insurance through: SEARCHING ONLINE? (Online Search) SOMEONE TELLING YOU ABOUT ALLCHOICE? (Referral) – or maybe – DID YOU SEE AN AD? (Advertisement)
(Required)
Online Search
Referral
Advertisement
Great! When you conducted the online search, which search engine did you use? (e.g., Google, Bing, Yahoo)
(Required)
Could you please share the specific keywords or phrases you used during your online search to find ALLCHOICE Insurance?
(Required)
After finding us through the online search, what specific factors or information stood out to you that led you to choose ALLCHOICE Insurance?
(Required)
Thank you for sharing! Who referred you to ALLCHOICE Insurance? We'd love to know so we can extend our appreciation.
(Required)
Could you tell us more about your experience with the person or source who referred you to us? Understanding your referral experience helps us enhance our client relationships.
(Required)
Was there anything in particular about the referral that influenced your decision to reach out to ALLCHOICE Insurance?
(Required)
Excellent! Where did you encounter our advertisement? Was it on social media, a website, radio, TV, or elsewhere?
(Required)
Can you recall the content or message of the advertisement that caught your attention? Understanding what resonates with our audience helps us refine our advertising strategies.
(Required)
After seeing our advertisement, what prompted you to take the next step and reach out to ALLCHOICE Insurance? We're interested in knowing what motivated your decision
(Required)
Confirmation
Please review your information to ensure all fields are filled before submitting.
(Required)
I confirm that all the information provided above is accurate and complete.
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