[LAVA] Agent Entered Personal Fast App Agent Entered Personal Fast App Agent Name (You)(Required)Doug BenzLiz BenzLouise PhillipsNoah ThiesSamantha HymanName Insured(Required) First Last Email(Required) Phone(Required)Birthdate(Required) MM slash DD slash YYYY Gender(Required)MaleFemaleNon-binaryMarital Status(Required)SingleSignificant OtherMarriedOccupation(Required)Employment/Position(Required)Company/School Name(Required)Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Spouse/Significant Other(Required) First Last Gender(Required)MaleFemaleNon-binarySpouse/Significant Other DOB(Required) MM slash DD slash YYYY Spouse/Significant Other PhoneSpouse/Significant Other Email Spouse/Significant Other Employment Status(Required)EmployedSelf EmployedRetiredHomemakerStudentOccupationCompany/School NamePoliciesClick all that apply(Required) Auto/Home(Discount) Auto Home 2nd Home Landlord Condo/Townhome Renters Umbrella Life Insurance Boat ATV/OHV/Golf Cart RV/Travel Trailer Motorcycle Pet Policy Start Date(Required) MM slash DD slash YYYY How did you find us?(Required) Referral Google Social Media Escrow Lender/Realtor Other Who shall we thank for referring you?Home Details - 60% CompleteIs this new construction?(Required) Yes No Estimated Close Date(Required) MM slash DD slash YYYY Property usage(Required)Primary ResidenceSecond HomeRentalProperty type(Required)Single Family ResidenceCondoApartmentDuplexTriplex4PlexPercentage of time at this home(Required)Unoccupied for more than 30 days in a row(Required) Yes No Will you rent this home(Required) Yes No Shortest rental duration allowed(Required)DailyWeeklyMonthly6+ MonthsLease duration Long term (6+ mo.) Short term (less than 6 mo.) Shortest rental duration allowedDailyWeeklyMonthlyHome Address (to be insured)(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Bathrooms(Required)11.522.533.544.55678910+Age of Roof(Required)Pool/Hot Tub(Required)NonePoolHot TubPool and Hot TubTrampoline(Required) Yes No Does the trampoline include safety netting(Required) Yes No Is it located in a fenced yard(Required) Yes No Does the pool have a slide(Required) Yes No Does the pool have a diving board(Required) Yes No Home updates (check all that apply) Electrical HVAC Plumbing All must be updated in past 25 yearsElectrical - Year updated(Required)HVAC - Year updated(Required)Plumbing - Year updated(Required)Discount questions (click all that apply)(Required) Fire Alarm (Monitored 24/7 Central Station) Fire Alarm (Local) Burglar Alarm (Monitored 24/7 Central Station) Burglar Alarm (Local) Fully Sprinklered Inside HOA Guard Gated Automatic Closing Gate Water Leak Detection None Dogs(Required) Yes No Breed of dog(s)(Required)Home Details - 70% CompleteYear Built(Required)Square Feet(Required)Garage(Required)None1 Car2 Car3 Car4 Car1 Car Detached2 Car Detached3 Car Detached4 Car DetachedBathrooms(Required)11.522.533.544.55678910+Stories(Required)11.523+Exterior Construction(Required)StuccoWoodAluminumBrickClapboardHardiplank (fiber cement)VinylStoneFireplace(Required)None123Foundation(Required)BasementBasement - WalkoutCrawl SpaceSlabRoof(Required)Asphalt ShinglesArchitectural ShinglesMetalSlabTile - Clay/ConcreteRolledWoodFlatOtherPool/Hot Tub(Required)NonePoolHot TubPool and Hot TubTrampoline(Required) Yes No Is it located in a fenced yard(Required) Yes No Does the trampoline include safety netting(Required) Yes No Does the pool have a slide(Required) Yes No Does the pool have a diving board(Required) Yes No Discount questions (click all that apply)(Required) Fire Alarm (Monitored 24/7 Central Station) Fire Alarm (Local) Burglar Alarm (Monitored 24/7 Central Station) Burglar Alarm (Local) Fully Sprinklered Inside HOA Guard Gated Automatic Closing Gate Water Leak Detection None Dogs(Required) Yes No Breed of dog(s)(Required)2nd HomeAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Bathrooms(Required)11.522.533.544.55678910+Age of Roof(Required)Pool/Hot Tub(Required)NonePoolHot TubPool and Hot TubTrampoline(Required) Yes No Does the trampoline include safety netting(Required) Yes No Is it located in a fenced yard(Required) Yes No Does the pool have a slide(Required) Yes No Does the pool have a diving board(Required) Yes No Home updates (check all that apply) Electrical HVAC Plumbing All must be updated in past 25 yearsElectrical - Year Updated(Required)HVAC - Year Updated(Required)Plumbing - Year Updated(Required)Discount questions (click all that apply) Fire Alarm (Monitored 24/7 Central Station) Fire Alarm (Local) Burglar Alarm (Monitored 24/7 Central Station) Burglar Alarm (Local) Fully Sprinklered Inside HOA Guard Gated Automatic Closing Gate Water Leak Detection None Dogs(Required) Yes No Breed of dog(s)(Required)Condo DetailsYear built(Required)Square Feet(Required)Garage(Required)None1 Car2 CarBathrooms(Required)11.522.533.544.55678910+# Stories(Required)11.523+Fireplace(Required)None123Discount questions (click all that apply)(Required) Fire Alarm (Monitored 24/7 Central Station) Fire Alarm (Local) Burglar Alarm (Monitored 24/7 Central Station) Burglar Alarm (Local) Fully Sprinklered Inside HOA Guard Gated Automatic Closing Gate Water Leak Detection Water Leak Detection Have you had any prior claims in the last 5 years(Required) Yes No Prior claim details(Required)Include Year and Property AddressDogs(Required) Yes No Breed of dog(s)(Required)RentersProperty type(Required)Single Family ResidenceCondoApartmentDuplexTriplex4plexExterior Construction(Required)StuccoWoodAluminumBrickClapboardHardiplank (fiber cement)VinylStoneSquare Feet(Required)Dogs(Required) Yes No Breed(s)(Required)Discount questions (click all that apply)(Required) Fire Sprinklers Gated Community Monitored Alarm None Investment Property Details Is this a new construction? Is this owned in the name of an entity? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Auto Details - 75% Complete!Current auto insurance company(Required)Driver Details Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Vehicle Details Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. UmbrellaNumber of residences you occupy(Required) 0 1 2 3 4+ Number of rental units you own(Required) 0 1 2 3 4+ Number of drivers(Required) 0 1 2 3 4+ Any driver under 25(Required) Yes No Number of auto you own(Required) 0 1 2 3 4+ Any boats, RVs, motorcycles, or other vehicles you own?(Required) Yes No Life InsuranceDesired Amount(Required)Term length(Required)20 Years30 YearsPermanentHeight(Required)Weight(Required)Current life insurance in force Yes No Current life insurance amount(Required)Current life insurance company(Required)Do you or have you ever smoked tobacco(Required) Yes No Quantity(Required)Frequency(Required)Form(Required)Last Used(Required)Have you used marijuana in the last 5 years (Don't worry, you're still insurable)(Required) Yes No Have you seen a doctor in the last 5 years(Required) Yes No Please indicate the approximate date and the reason for the visit(Required)Are you taking any prescription medication(Required) Yes No Boat DetailsBoat Driver Details Name Birthdate Driver's License # Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Boat new or used(Required) Yes No Date purchased(Required) MM slash DD slash YYYY Boat Value(Required)Boat Year(Required)Boat Make(Required)Boat Model(Required)Boat Length(Required)Propulsion Type(Required)OutboardInboard/OutboardInboardJetHorse power(Required)Maximum speed(Required)Hull ID(Required)Construction material(Required)Fiberglass, Aluminum, Wood, etc.Leased/Rented to others(Required) Yes No Watercraft stored at home address(Required) Yes No Watercraft Storage Location(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Used for business(Required) Yes No Previously salvaged(Required) Yes No Permanent living quarters(Required) Yes No High performance (Fast)(Required) Yes No Number of motors(Required) 1 2 3+ Exposed engine, other than outboard(Required) Yes No Corporate owned(Required) Yes No Name of Owner(Required)Do you have a lienholder(Required) Yes No Lienholder(Required)Any additional equipment(Required)Protective devices(Required)Do you have a trailer to insure(Required) Yes No Trailer year(Required)Trailer make(Required)Trailer model(Required)Trailer value(Required)Trailer ID/Serial #(Required)ATV/OHV/Golf Cart DetailsCurrent auto insurance company(Required)Driver Details Name Birthdate Driver's License # Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Other Vehicle Details Vehicle Type Details Vehicle Use Vehicle Use Details Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. RV/Travel Trailer DetailsRV Driver Details Name Driver's License # Original Date License Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Year(Required)Make(Required)Model(Required)Length (in ft)(Required)How many slides(Required)Year PurchasedEstimated value today(Required)VIN#How many days per year is it used(Required)RV rented commercially or used for business purposes(Required) Yes No RV rented to others(Required) Yes No RV taken to and from work or used at a work location(Required) Yes No Primary vehicle use(Required)Recreational UsePrimary ResidenceFull-timerStored at home(Required) Yes No Storage address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Motorcycle DetailsCurrent auto insurance companyMotorcycle endorsement(Required) Yes No Years with MC endorsement(Required)Safety course completion(Required) Yes No Completion date(Required) MM slash DD slash YYYY Rider Details Name Birthdate Driver's License # Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Motorcycle Details Year Make Model VIN # Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Pet DetailsPet Details Pet Name Pet Type Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Upload a copy of your current coverages (Declaration pages) Drop files here or Select files Max. file size: 39 MB. Is there any additional information we should be aware of?
