Source:
Quoting Agent:
Please Select
Melissa
Rob
Aimee
Erin
Grace
Multiple Quotes?
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1
2
3
4
5
6
File Upload:
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Agent that took the info:
Please Select
Rob
Melissa
Erin
Aimee
Grace
Website
Time Stamp:
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Full Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Phone Number:
*
Please enter a valid phone number.
Email Address:
*
example@example.com
Would you like to receive a text when your quote is ready? (We will never send you promotional or marketing messages)
Yes
No
Would you like to add an additional named insured?
Yes
No
Second Named Insured:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Property Address:
Do you have a separate mailing address?
Yes
No
Mailing Address:
*
Preferred Contact Method:
Phone
Email
Text
How did you hear about Allen Duncan? (Select all the apply)
*
Internet / Website
Facebook
Existing / Prior
Friend /Co-Worker / Relative
Neighbor
Realtor
Other
Have we helped you with insurance before?
*
Yes - Current Client
Yes - Former Client
No - New Client
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What can we help you with today? (If you would like a home and auto bundle quote, select Home first and hit next at the end to enter your auto info)
*
Homeowners Insurance
Auto Insurance
Mobile Homeowners Insurance
Condo Insurance
Renters Insurance
Flood Insurance
Life Insurance
Commercial Auto
General Liability
Umbrella
Other
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Is this your primary residence?
Yes
No
Do you rent to others?
Yes
No
If this is a seasonal / secondary home for you please tell us how much time you spend here...
Number of months during the year that you reside at the condo
Mobile Home size:
Please put the length and width / square footage
How much coverage?
This is just an estimate, it gives us an idea of what your expectations are.
Please enter any attached structures:
This includes carports, screen porches, lanai, sheds, utility rooms, ect...
Is this your primary residence?
Yes
No
Is it a new purchase?
Yes
No
Is the property insured?
Yes
No
What is your current company?
Are you up for renewal?
Yes
No
Renewal Date:
-
Month
-
Day
Year
Date
What is your current address?
Closing Date:
-
Month
-
Day
Year
Date
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Next
What year was the roof last replaced?
Did you get a wind mitigation inspection? (They are good for 5 years)
Yes
No
Have you had a 4-point inspection completed in the last year?
Yes
No
You can attach any inspections you have here. (You can also email them to rob@allenduncan.com)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please list all animals on the property. (Type / Breed)
Please describe any and all claims on the property in the last 5 years. (Weather / Hurricane / Liability / Water / Flood / Fire / ect)
Any additional comments here:
Please press submit if you just need a homeowner's quote today. Or, you can press next to shop your auto insurance as well!
(You will need basic info like drivers, vehicles, and how you'd like to be covered)
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Submit
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What is the name of your business?
What is your primary trade / occupation?
Do you currently have auto insurance?
Yes
No
Who are you currently insured with?
Are you up for renewal?
Yes
No
What is your renewal date?
-
Month
-
Day
Year
Date
When does your current policy expire?
-
Month
-
Day
Year
Date
How many Drivers do you need to add?
*
Please Select
1
2
3
4
Driver 1:
*
First Name
Last Name
DOB 1:
*
-
Month
-
Day
Year
Date
Drivers License 1:
Driver 2:
*
First Name
Last Name
DOB 2:
*
-
Month
-
Day
Year
Date
Drivers License 2:
Driver 3:
*
First Name
Last Name
DOB 3:
*
-
Month
-
Day
Year
Date
Drivers License 3:
Driver 4:
*
First Name
Last Name
DOB 4:
*
-
Month
-
Day
Year
Date
Drivers License 4:
How many vehicles do you have?
Please Select
1
2
3
4
Vehicle 1: VIN (this information will make your quote much more accurate)
Vehicle 1: Make / Model / Year (please provide so we can confirm the VIN)
*
Vehicle 1 Usage:
Please Select
Commute
Pleasure
Business
What do you mainly use the vehicle for?
Vehicle 1 - Comprehensive Deductible
Please Select
No Coverage
50
100
250
500
750
1000
Comprehensive Deductible: Your out of pocket cost if the car is damaged by theft, weather, or vandalism. (Windshields have zero deductible when you have comprehensive coverage.
Vehicle 1 - Collision Deductible:
Please Select
No Coverage
50
100
250
500
750
1000
Collision Deductible: Your out of pocket cost if the car is damaged in an accident.
Vehicle 1 - Rental Reimbursement
Please Select
Decline
30/900
40/120
50/1500
This coverage helps you pay for a rental vehicle if your vehicle is being repaired from a claim. It often costs just a few dollars a month.
Vehicle 1 - Roadside Assistance
Please Select
Yes
No
This coverage helps you pay for a tow bill, or can dispatch someone to help you if you are stuck on the side of the road. It often costs just a few dollars a month.
Vehicle 2: VIN (this information will make your quote much more accurate)
Vehicle 2: Make / Model / Year (please provide so we can confirm the VIN)
*
Vehicle 2 Usage:
Please Select
Commute
Pleasure
Business
Vehicle 2 - Comprehensive Deductible
Please Select
No Coverage
50
100
250
500
750
1000
Comprehensive Deductible: Your out of pocket cost if the car is damaged by theft, weather, or vandalism. (Windshields have zero deductible when you have comprehensive coverage.
Vehicle 2 - Collision Deductible:
Please Select
No Coverage
50
100
250
500
750
1000
Collision Deductible: Your out of pocket cost if the car is damaged in an accident.
Vehicle 2 - Rental Reimbursement
Please Select
I decline
30/900
40/120
50/1500
This coverage helps you pay for a rental vehicle if your vehicle is being repaired from a claim. It often costs just a few dollars a month.
Vehicle 2 - Roadside Assistance
Please Select
Yes
No
This coverage helps you pay for a tow bill, or can dispatch someone to help you if you are stuck on the side of the road. It often costs just a few dollars a month.
Vehicle 3: VIN (this information will make your quote much more accurate)
Vehicle 3: Make / Model / Year (please provide so we can confirm the VIN)
*
Vehicle 3 Usage:
Please Select
Commute
Pleasure
Business
Vehicle 3 - Comprehensive Deductible
Please Select
No Coverage
50
100
250
500
750
1000
Comprehensive Deductible: Your out of pocket cost if the car is damaged by theft, weather, or vandalism. (Windshields have zero deductible when you have comprehensive coverage.
Vehicle 3 - Collision Deductible:
Please Select
50
100
250
500
750
1000
Collision Deductible: Your out of pocket cost if the car is damaged in an accident.
Vehicle 3 - Rental Reimbursement
Please Select
I decline
30/900
40/1200
50/1500
This coverage helps you pay for a rental vehicle if your vehicle is being repaired from a claim. It often costs just a few dollars a month.
Vehicle 3 - Roadside Assistance
Please Select
Yes
No
This coverage helps you pay for a tow bill, or can dispatch someone to help you if you are stuck on the side of the road. It often costs just a few dollars a month.
Vehicle 4: VIN (this information will make your quote much more accurate)
Vehicle 4: Make / Model / Year (please provide so we can confirm the VIN)
*
Vehicle 4 Usage:
Please Select
Commute
Pleasure
Business
Vehicle 4 - Comprehensive Deductible
Please Select
No Coverage
50
100
250
500
750
1000
Comprehensive Deductible: Your out of pocket cost if the car is damaged by theft, weather, or vandalism. (Windshields have zero deductible when you have comprehensive coverage.
Vehicle 4 - Collision Deductible:
Please Select
50
100
250
500
750
1000
Collision Deductible: Your out of pocket cost if the car is damaged in an accident.
Vehicle 4 - Rental Reimbursement
Please Select
I decline
30/900
40/120
50/1500
This coverage helps you pay for a rental vehicle if your vehicle is being repaired from a claim. It often costs just a few dollars a month.
Vehicle 4 - Roadside Assistance
Please Select
Yes
No
This coverage helps you pay for a tow bill, or can dispatch someone to help you if you are stuck on the side of the road. It often costs just a few dollars a month.
Policy Coverage for Bodily Injury:
Please Select
10/20
25/50
50/100
100/300
250/500
300/300
500/500
This covers injuries you cause to other people in an accident. Limits are shown as per person/ per accident.
Policy Coverage for Property Damage:
Please Select
10
25
50
100
250
500
This covers damage your vehicle causes to someone else’s car or property in an accident.
Policy Coverage for Uninsured Motorist:
Please Select
Same as Bodily Injury
Reject UM
10/20
25/50
50/100
100/300
300/300
250/500
500/500
1,000,000
This is coverage for you if you are injured by an at-fault party that has no insurance or is under-insured.
Is the Uninsured Motorist "Stacked" or "Non-Stacked"
Please Select
Reject UM
Stacked
Non-Stacked
Please list any claims or accidents both at-fault and not at-fault / tickets / citations
Any additional comments here:
Press submit if you have completed your info, otherwise press next to add a Life insurance quote today!
(Just four simple questions.....)
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Submit
Next
Please list the Name and DOB of applicant:
*
Desired Term:
*
Please Select
10 Years
20 Years
30 Years
Not Sure (We will quote them all)
Desired Coverage Amount:
*
Please Select
$10,000
$25,000
$50,000
$100,000
$250,000
$500,000
$1,000,000
Not Sure (We will quote them all!)
Press submit if you have completed your info, otherwise press next to add a Renters insurance quote today!
(Just five simple questions.....)
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Submit
Next
How much coverage do you need?
Please Select
10,000
25,000
50,000
75,000
100,000
Type of dwelling?
Please Select
Single Family Home
Apartment
Duplex
Triplex
Quad
Other
What year was the roof replaced?
Please describe any and all claims on the property in the last 5 years. (Weather / Hurricane / Liability / Water / Flood / Fire / ect)
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Submit
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Please place any additional comments here:
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Do you have flood insurance now?
Yes
No
What is your renewal date?
-
Month
-
Day
Year
Date
Please let us know if you have had any flood claims in the last 5 years. (Date and Description)
Please provide any additional notes:
Submit
Should be Empty: