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Named
Insured/Spouse |
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Address |
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City & Zip |
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Email Address |
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Phone Number |
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Fax Number |
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Best Time To
contact |
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If you don't
want to complete the rest of this web form,
we will get this information via a telephone
conversation. -
SUBMIT
NOW!
THE
FOLLOWING OPTIONAL DATA IS NOT REQUIRED BUT
WILL SPEED UP THE QUOTE PROCESS!
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Has there been Claims,
Accidents, or Violations in the last three
years? |
1.
Description
Date:
Amount Paid
(if claim)
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2.
Description
Date:
Amount Paid
(if claim)
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3.
Description
Date:
Amount Paid
(if claim)
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Are you
being non-renewed by your current insurance
carrier?
Yes
No |
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Have you
filed bankruptcy in the last 7 years?
Yes
No |
Info if
Yes:
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Household
Members
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Child
away at school?
Yes
No
Other
Information
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Vehicle
Information
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Any
Auto's Used for any business activity for
yourself or others?
Yes
No |
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Any
Campers of Trailers?
Yes
No |
If Yes,
Details:
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Present Coverages:
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If you have more than 5 vehicles, please
list them in the comments section at the
end.
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HUGE DISCOUNTS ARE AVAILABLE
IF YOU OWN YOUR OWN HOME
AND WE INSURE THAT AS WELL. IF YOU OWN YOUR
HOME OR CONDO OR RENT,
PLEASE COMPLETE THIS INFORMATION.
Homeowners/Renters/Condo
Proposal Info - Don-Rick, Inc.
Note-For Renters/Condos
Proposal Complete Questions with (*)
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Construction
Type (frame or Concrete):
Year Built:
Square Footage Living Area:
Mileage
to Nearest Fire Station:
Within City Limits?
Heat
Type:
If Not In City, In Subdivision?
# of
Units in Building:
Fireplace/Woodstove/alternative heat?
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Personal Limits
Dwelling:
Other structures:
Personal
Property:
Personal Liability:
Deductible:
Medical Payments:
*Do you
have any items that should be scheduled?
(Jewelry, Fine Arts, Guns)
*Do you
have any recreational vehicles?
– If yes, please describe and provide values
and CC’s or Horsepower ratings.
*Do you
have a personal umbrella?
– If yes, present limit
Would you like a proposal on an umbrella?
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