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Request a Home Quote from Mike
Mike Schmisek
2022-01-12T09:29:43-07:00
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Name
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Address
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Address Line 1
City
State / Province / Region
Postal Code
Phone Number
*
Email Address
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What type of roof do you have (i.e. asphalt, wood shake, concrete tile, etc)?
*
When was your roof last replaced?
When was your furnace last replaced?
When was your plumbing last replaced?
When was your electrical last replaced?
Do you have a basement?
*
Yes
No
Is it finished?
*
What percentage?
*
Do you currently have insurance?
*
Yes
No
What company currently insures your house?
*
Do you have a mortgage?
*
Yes
No
Is the home insurance premium paid by your escrow company?
*
Yes
No
When did you purchase your house?
First
Last
Do you have a dog?
*
Yes
No
What kind?
*
Has your dog ever bitten someone causing injury?
*
Would you like a quote on your auto insurance?
*
Yes
No
What is your Driver’s License Number:
*
What do you do for a living?
Any additional drivers?
*
Yes
No
Name
*
First
Last
Date of Birth
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Driver’s License Number:
*
What do they do for a living?
What is this person's relationship to you ?
*
Spouse
Parent
Son
Daughter
Roommate
Other
Any additional drivers?
*
Yes
No
Name
*
First
Last
Date of Birth
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Driver’s License Number
*
What do they do for a living?
What is this person's relationship to you ?
*
Spouse
Parent
Son
Daughter
Roommate
Other
Any additional drivers?
*
Yes
No
Name
*
First
Last
Date of Birth
*
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1931
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1928
1927
1926
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1924
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1922
1921
1920
Driver’s License Number
*
What do they do for a living?
What is this person's relationship to you ?
*
Spouse
Parent
Son
Daughter
Roommate
Other
Any additional drivers?
*
Yes
No
Name
*
First
Last
Date of Birth
*
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Driver’s License Number
*
What do they do for a living?
What is this person's relationship to you ?
*
Spouse
Parent
Son
Daughter
Roommate
Other
Any additional drivers?
*
Yes
No
Name
*
First
Last
Date of Birth
*
MM
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1951
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1941
1940
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1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Driver’s License Number
*
What do they do for a living?
What is this person's relationship to you ?
*
Spouse
Parent
Son
Daughter
Roommate
Other
Vehicles
VIN
Year
*
Make
*
Model
*
Collision Coverage
*
No
$250 deductible
$500 deductible
$1000 deductible
Comprehensive Coverage
*
No
$250 deductible
$500 deductible
$1000 deductible
Rental Reimbursement
*
No
$25 per day
$50 per day
$100 per day
Towing and Roadside Assistance
*
Yes
No
Lien or Lease?
*
Lease
Lien
owned – no payments
Additional Vehicles?
*
Yes
No
VIN
Year
*
Make
*
Model
*
Collision Coverage
*
No
$250 deductible
$500 deductible
$1000 deductible
Comprehensive Coverage
*
No
$250 deductible
$500 deductible
$1000 deductible
Rental Reimbursement
*
No
$25 per day
$50 per day
$100 per day
Towing and Roadside Assistance
*
Yes
No
Lien or Lease?
*
Lease
Lien
owned – no payments
Additional Vehicles?
*
Yes
No
VIN
Year
*
Make
*
Model
*
Collision Coverage
*
No
$250 deductible
$500 deductible
$1000 deductible
Comprehensive Coverage
*
No
$250 deductible
$500 deductible
$1000 deductible
Rental Reimbursement
*
No
$25 per day
$50 per day
$100 per day
Towing and Roadside Assistance
*
Yes
No
Lien or Lease?
*
Lease
Lien
owned – no payments
Additional Vehicles?
*
Yes
No
VIN
Year
*
Make
*
Model
*
Collision Coverage
*
No
$250 deductible
$500 deductible
$1000 deductible
Comprehensive Coverage
*
No
$250 deductible
$500 deductible
$1000 deductible
Rental Reimbursement
*
No
$25 per day
$50 per day
$100 per day
Towing and Roadside Assistance
*
Yes
No
Lien or Lease?
*
Lease
Lien
owned – no payments
Additional Vehicles?
*
Yes
No
VIN
Year
*
Make
*
Model
*
Collision Coverage
*
No
$250 deductible
$500 deductible
$1000 deductible
Comprehensive Coverage
*
No
$250 deductible
$500 deductible
$1000 deductible
Rental Reimbursement
*
No
$25 per day
$50 per day
$100 per day
Towing and Roadside Assistance
*
Yes
No
Towing and Roadside Assistance
*
Yes
No
Lien or Lease?
*
Lease
Lien
owned – no payments
Do you currently have car insurance?
*
Yes
No
What company are you currently insured with?
*
Why haven’t you had car insurance (i.e. didn’t have a car, out of the country, covered by a work vehicle, etc)
*
Many companies offer a discount if you’re willing to download a mobile app to your phone that will score your driving. Would you be willing to download this app for 6 months or less?
*
Yes
No
How did you hear about our agency?
*
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