Schmit Insurance Group Quote Form
Applicant's Name
First Name Last Name
HOW DID YOU HEAR ABOUT US?*
What has you shopping? e.g. price, coverage, customer service, bad claims experience, etc
Explain what makes us different from other Agencies:
- Broker vs. Direct/Captive Agencies
- Client FOCUSED Agency
- Referral only agency... We want to do business we know like and trust just like you.
I want quotes on:
Auto Home Specialty/Toy Business Life
Phone #
Email
Applicant Date of Birth
00/00/0000
Are you Married?
Yes No
Co-Applicant's Name
First Name Last Name
Co-Applicant Date of Birth
00/00/0000
Occupation('s)
Include Applicant & Co-Applicant job descriptions
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code

Auto Info:
Currently Insured: Yes/No
Yes No
Current Carrier
Current Policy Expiration Date
Month Day Year
Date
Number of Drivers
Driver #1: Name
Driver #1: Date of Birth
Month Day Year
Date
Driver #1: DL #
Driver #2: Name
Driver #2: Date of Birth
Month Day Year
Date
Driver #2: DL #
Driver #3: Name
Driver #3: DL #
Driver #3: Date of Birth
Month Day Year
Date
Driver #4: Name
Driver #4: Date of Birth
Month Day Year
Date
Driver #4: DL #
ADDITIONAL DRIVERS - (name, birth date, DL#)
Number of Vehicles
Vehicle #1: Year/Make/Model/VIN#
Vehicle #1 Coverage Options: Select all that apply
Liability Comprehensive Collision Towing/Roadside Full Glass Rental Reimbursement
Vehicle #1: Comprehensive Deductible Option:
$100 $250 $500 $1000 OTHER
Vehicle #1: Collision Deductible Option:
$100 $250 $500 $1000 OTHER
Vehicle #2: Year/Make/Model/VIN#
Vehicle #2 Coverage Options: Select all that apply
Liability Comprehensive Collision Towing/Roadside Full Glass Rental Reimbursement
Vehicle #2: Comprehensive Deductible Option:
$100 $250 $500 $1000 OTHER
Vehicle #2: Collision Deductible Option:
$100 $250 $500 $1000 OTHER
Vehicle #3: Year/Make/Model/VIN#
Vehicle #3 Coverage Options: Select all that apply
Liability Comprehensive Collision Towing/Roadside Full Glass Rental Reimbursement
Vehicle #3: Comprehensive Deductible Option:
$100 $250 $500 $1000 OTHER
Vehicle #3: Collision Deductible Option:
$100 $250 $500 $1000 OTHER
Vehicle #4: Year/Make/Model/VIN#
Vehicle #4 Coverage Options: Select all that apply
Liability Comprehensive Collision Towing/Roadside Full Glass Rental Reimbursement
Vehicle #4: Comprehensive Deductible Option:
$100 $250 $500 $1000 OTHER
Vehicle #4: Collision Deductible Option:
$100 $250 $500 $1000 OTHER
Additional Vehicle Info: Year/Make/Model/VIN# - INCLUDE Coverage & Deductible Info -
Additional Info/Notes

Home Info:
Is this for a new home purchase/closing?
Yes No
Closing Date?
Month Day Year
Date
Mortgagee & Lender Info
New Home Address:
Current Home Address:
Currently Insured?
Yes No
Current Carrier
Current Policy Expiration Date
Month Day Year
Date
Home Style: (1 Story, 2 Story, etc.)
Year Home Was Built
Square Feet (Above Ground)
Year of Roof
Roof Material
Year of Heat
Heating Type
Central Air:
Yes No
Year of Electric
CB or Fuse
CB Fuse
Fuel Source:
Fireplace:
Yes No
Type of Fireplace: i.e. Woodstove, electric, gas, pellet, outdoor woodstove, etc.
Number Full Bath
Number Half Bath
Basement: Yes/No
Yes No
Percent of Basement Finished
Walkout: Yes/No
Yes No
Garage: Attached/Detached
Attached Detached
Garage Size (1 Stall, 2 Stalls, etc.)
Deck/Porch Square Feet
Any Dogs: Yes/No (If yes, list breed)
Swimming Pool:
Yes No
Trampoline:
Yes No
HIGH VALUE ITEMS: (Itemized coverage for jewelry, guns, etc)
Additional Info: (Dwelling Value, Deductible, Sewer, etc... CURRENT PREMIUM)

REC VEHICLE / TOY
TYPE: (Select All That Apply)
Boat/Watercraft ATV/UTV/Golf Cart Motorcycle/Moped Camper/Trailer Snowmobile OTHER
Number of Boats/Watercrafts
Boat #1: YEAR / MAKE / MODEL / LENGTH
Boat #1: MOTOR - YEAR / MAKE / MODEL / HP
Boat #1: Do you want insurance on boat trailer?
Yes No
Boat #1: OVERALL VALUE
Boat #2: YEAR / MAKE / MODEL / LENGTH
Boat #2: MOTOR - YEAR / MAKE / MODEL / HP
Boat #2: Do you want insurance on boat trailer?
Yes No
Boat #2: OVERALL VALUE
BOAT / WATERCRAFT : ADDITIONAL INFO
Should be Empty: