Detailed Quote Form Step 1 of 16 6% What type of insurance can we quote for you? Auto Home Condo Renters Mobile Home Umbrella Rental Property Motorcycle/Slingshot/ATV Golf Cart Boat RV Jetski Other We are not providing auto only quotes at this timeHow did you hear about us?(Required)WebsiteRealtor ReferralMortgage ReferralCustomer ReferralGoogleFacebookCurrent CustomerInternal Referral (Office Use Only)Mario Riccadonna, Note AdvisorsDo you currently have auto insurance?(Required)YesNo*****Based on the information provided, we do not have any carriers that will allow us to quote automobile policies without prior coverage in force. If you have any questions, please text us at 716-514-4040. Thank you for your time.*****This field is hidden when viewing the formHawksoft Policy TypeAUTOPThis field is hidden when viewing the formAssigned AdvisorDoug BenzLiz BenzNoah ThiesInternal Referral SourcesAAA InsuranceAAA Prior CustCarrier DirectCross-SellCurrent CustomerCustomer ReferCustomer ReferralDavis LawExtra Mile WebsiteFacebookFamilyFRMS- Gordon, TGold StarGold StarGoogle/Search EngineIAOAIns Agnt-UnknownInstagramLinkedInMtg-1st UnitedMtg-ArvestMtg-Flat BrnchMtg-GatewayMtg-Nw Am FundMtg-Pro MtgMtg-UFFCMtg-UFFC-TahlMtg-unknownMtg-ZfgNetwking eventNetworkingOLT-B. ParkerPersonal FrndProfessional ReferralRealtorRemarketRewriteRltr- OtherRltr-Chin&CohnRltr-Cnt21Rltr-Coldw BnkRltr-EXPRltr-Klr WlmsSF-BillingsSF-Bryan SmithSF-S. LaneSF-T.BledsoeWalk-inWinbackWho Referred You?What other type of insurance can we quote for you?Primary Contact InformationPrimary Insured Name (as it appears on your Driver’s License)(Required) First Middle Last Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY SSNOccupationAre you a AAA member?YesNoAAA Membership NumberMarital Status(Required) Single Married Divorced Widowed Spouse InformationSpouse Name(Required) First Middle Last Spouse Phone(Required)Spouse Email Spouse OccupationSpouse Date of Birth(Required) MM slash DD slash YYYY Spouse SSN Current Address(Required) Street Address Address Line 2 City ZIP Code State(Required)ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYOwn or Rent?(Required)I own this property (mortgage)I own this property (no mortgage)I rent this propertyThis field is hidden when viewing the formCountyErieCattaraugusGeneseeNiagaraWyomingMailing address different than location address?NoYesMailing Address Street Address Address Line 2 City ZIP Code State(Required)ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYYears at current address3+ Years0-3 YearsPrior Address(Required) Street Address Address Line 2 City ZIP Code State(Required)ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Home/Condo InformationProperty TypeSingle FamilyMulti FamilyCondoFarm/RanchVacant LandNew purchase or already own the condo/home? New Purchase Already Own How do you use the condo? Primary Residence Secondary Residence Rental Purchase Date/Closing Date Month Day Year # of stories 1 1.5 2 Roof MaterialComposite ShinglesAsphalt ShinglesArchitectural ShinglesMetalTileYear Roof UpdatedAny updates to heating, electrical or plumbing? Heating Electrical Plumbing Year Heating UpdatedType of UpdateFull ReplacementPartial UpdateYear Electrical UpdatedType of UpdateFull ReplacementPartial UpdateYear Plumbing Updated?Type of UpdateFull ReplacementPartial UpdateFoundationBasementCrawlspaceSlabFinished Basement %Garage Yes Attached Yes Detached Car Port None Garage 1 Car 2 Car 3 Car 4 Car Detached Structures Yes No Detatched StructureYear BuiltDetached Structure Sq. FootageWhat Type of Structure?GarageShopShedBarnPool HouseOtherWhat Other Type?Detatched Building ExteriorWoodMetalVinylOtherOther Exterior MaterialDetatched Structure Roof TypeAsphalt ShingleMetalOtherOther Roof TypeDetatched Building Roof AgeDetached Structures Used For Farming Purposes? Yes No Which building and how is it used?Fireplace Yes - Gas Yes - Wood No Woodstove Yes No More than 5 AcresDeck/Patio Yes - Covered Yes - Screened Yes - Enclosed No Deck/Patio SizeBathrooms11.522.533.544.5Swimming Pool Yes No Swimming Pool Fenced and Locked? Yes No Diving Board or Slide? Yes No Trampoline Yes No Trampoline Has A Net? Yes No Monitored Burglar/Fire Alarm? Local Monitored None Monitored Alarm Company NameResponding Fire Department?Miles to Fire Department?Any Pets?CatDogCat & DogOtherNoDog Breeds Add RemoveIf mixed please indicate type of mix.Any bite history or security training? Yes No Mobile HomeWidthLengthTied Down Yes No In Approved Mobile Home Park? Yes No Name of Park?On Private Land? Yes No ManufacturerModelSerial #Any attached additions?If so, what?Done by professional? Yes No Condition of Mobile Excellent Good Poor If insured pays, how do they prefer to pay: Full Pay Two Pay Four Pay Monthly Could you send a front/back photo of your home if we write your insurance? Yes No New purchase or already own the condo/home? New Purchase Already Own How do you use the condo? Primary Residence Secondary Residence Rental Purchase Date/Closing Date Month Day Year # of stories 1 1.5 2 Roof MaterialComposite ShinglesAsphalt ShinglesArchitectural ShinglesMetalTileYear Roof UpdatedAny updates to heating, electrical, plumbing or roof? Heating Electrical Plumbing HeatingPartialCompleteYear of UpdateElectricalPartialCompleteYear of UpdatePlumbingPartialCompleteYear of UpdateRoofPartialCompleteYear of UpdateFoundationBasementCrawlspaceSlabFinished Basement %Garage Yes Attached Yes Detached Car Port None Garage 1 Car 2 Car 3 Car 4 Car Detached Structures Yes No Detatched StructureYear BuiltDetached Structure Sq. FootageWhat Type of Structure?GarageShopShedBarnPool HouseOtherWhat Other Type?Detatched Building ExteriorWoodMetalVinylOtherOther Exterior MaterialDetatched Structure Roof TypeAsphalt ShingleMetalOtherOther Roof TypeDetatched Building Roof AgeDetached Structures Used For Farming Purposes? Yes No Which building and how is it used?More than 5 acres? Yes No Fireplace Yes - Gas Yes - Wood No Woodstove Yes No Deck/Patio Yes - Covered Yes - Screened Yes - Enclosed No Deck/Patio SizeBathrooms11.522.533.544.5Swimming Pool Yes No Swimming Pool Fenced and Locked? Yes No Diving Board or Slide? Yes No Trampoline Yes No Trampoline Has A Net? Yes No Monitored Burglar/Fire Alarm? Local Monitored None Monitored Alarm Company NameResponding Fire Department?Miles to Fire Department?Any Pets?CatDogCat & DogOtherNoDog Breeds Add RemoveIf mixed please indicate type of mix.Any bite history or security training? Yes No Scheduled Personal Property Jewelry Furs Firearms Art Cameras Musical Instruments Other Total Value of Jewelry Owned?Total Value of Firearms Owned?Total Value of Art/Cameras/Furs/Musical Instruments Owned?Valuable Items List (Click the + to add additional items) Add RemovePlease list each item and include an appraised/estimated value. Only one item per row please.Home NotesCurrent Homeowners Insurance InformationCurrent CarrierPolicy Expiration MM slash DD slash YYYY Current PremiumEscrowed Yes No Mortgage CompanyHave there been any home claims in the last 5 years? Yes No Claims Add RemoveInclude Date of claim, Type of claim (wind/hail/water/lightning/other), Amount paid. Auto InformationTotal Drivers in Home(Required) 1 2 3 4 5 Total Vehicles in Home(Required) 1 2 3 4 5 Vehicle #1Vehicle YearVehicle MakeVehicle ModelVIN(Required)Example: 1HGCM82633A123456 *Vehicle Identification Numbers (VIN) do not use the letter characters I, O, and Q. This is to avoid confusion with the numbers 1 and 0. **Vehicle Identification Numbers have 17 characters.Vehicle #2Vehicle YearVehicle MakeVehicle ModelVIN(Required)Example: 1HGCM82633A123456 *Vehicle Identification Numbers (VIN) do not use the letter characters I, O, and Q. This is to avoid confusion with the numbers 1 and 0. **Vehicle Identification Numbers have 17 characters.Vehicle #3Vehicle YearVehicle MakeVehicle ModelVIN(Required)Example: 1HGCM82633A123456 *Vehicle Identification Numbers (VIN) do not use the letter characters I, O, and Q. This is to avoid confusion with the numbers 1 and 0. **Vehicle Identification Numbers have 17 characters.Vehicle #4Vehicle YearVehicle MakeVehicle ModelVIN(Required)Example: 1HGCM82633A123456 *Vehicle Identification Numbers (VIN) do not use the letter characters I, O, and Q. This is to avoid confusion with the numbers 1 and 0. **Vehicle Identification Numbers have 17 characters.Vehicle #5Vehicle YearVehicle MakeVehicle ModelVIN(Required)Example: 1HGCM82633A123456 *Vehicle Identification Numbers (VIN) do not use the letter characters I, O, and Q. This is to avoid confusion with the numbers 1 and 0. **Vehicle Identification Numbers have 17 characters.Driver #1 (Named Insured)Name(Required) First Last Drivers License #(Required)Drivers License State(Required)Any tickets or accidents in the last 5 years?DateDescription Add RemoveDriver #2Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY SSNAny tickets or accidents in the last 5 years?DateDescription Add RemoveDrivers License #(Required)Drivers License State(Required)Relationship to you Spouse Child Parent Other OccupationAny tickets or accidents in the last 5 years?DateDescription Add RemoveDriver #3Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY SSNDrivers License #(Required)Drivers License State(Required)Relationship to you Spouse Child Parent Other OccupationStudent Yes No Good Student Disocunt (GPA)Any tickets or accidents in the last 5 years?DateDescription Add RemoveDriver #4Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY SSNDrivers License #(Required)Drivers License State(Required)Relationship to you Spouse Child Parent Other OccupationStudent Yes No Good Student Disocunt (GPA)Any tickets or accidents in the last 5 years?DateDescription Add RemoveDriver #5Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY SSNDrivers License #(Required)Drivers License State(Required)Relationship to you Spouse Child Parent Other OccupationStudent Yes No Good Student Disocunt (GPA)Any tickets or accidents in the last 5 years?DateDescription Add Remove Current Auto Policy InformationCurrent Auto Insurer Name(Required)Current Policy Expiration Date MM slash DD slash YYYY Length of Time with Current Auto InsurerCurrent Monthly Auto Premium(Required)Pay Plan PreferredFull Pay2 Pay4 PayMonthly Rental PropertyRental Property Address Street Address Address Line 2 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 CountyAdairAlfalfaAtokaBeaverBeckmanBlaineBryanCaddoCanadianCarterCherokeeChoctawCimarronClevelandCoalComancheCottonCraigCreekCusterDelawareDeweyEllisGarfieldGarvinGradyGrantGreerHarmonHarperHaskellHughesJacksonJeffersonJohnsonKayKingfisherKiowaLatimerLeLincolnLoganLoveMajorMarshallMayesMcClainMcCurtainMcIntoshMurrayMuskogeeNobleNowataOkfuskeeOklahomaOkmulgeeOsageOttawaPawneePaynePittsburgPontotocPottawatomiePushmatahaRogerRogersSeminoleSequoyahStephensTexasTillmanTulsaWagonerWashingtonWashitaWoodsWoodwardShort-term rental? (VRBO, Air BnB, etc.)YesNoDays rented per yearOccupany StatusOwnerTenant(s)BothDays owner occupied per yearPersonal Property Coverage RequestedYear BuiltUnder Construction?YesNoSquare FeetStories11.52Construction TypeFrameMasonryFire ResistiveWhat type of siding?WoodVinylRoof TypeComposition ShinglesMetalWoodTileAge of roofFoundationSlabCrawlspaceGarage1c1.5c2c3cNo GarageGarage TypeAttachedDetachedCar Port# of bathsAny unfinished areas in your home?YesNoPlease specify the unfinished area(s)Floor TypeWood %Carpet %Ceramic %Vinyl %Laminate %OTHER (FILL IN)FireplaceYes - GasYes - WoodNoWood Burning StoveYesNoWas this installed by a professional?Central Heat/AirYesNoHeat/Air Type?Alarm Smoke alarm Dead bolt Monitored fire & burglar alarm Responding Fire Dept.Miles to Fire Dept.PCAnimalsYesNoWhat kind of animals?TrampolineYesNoTrampoline Safety Fenced Netting Swimming PoolYesNoPool Safety Fenced Locked Condition of homeExcellentVery GoodGoodPoorCurrent Carrier Motorcycle/ATVName of Primary Driver First Last Was vehicle purchased new? Yes No Current CarrierDrivers LicenseLicensed Motorcycle Endorsement Yes No Has Driver Completed Safety Course? Yes No Tickets or accidents in last 5 years? Add RemoveYears ExperienceVehicle Type Motorcycle Slingshot ATV Number of Wheels234UsagePleasureRacingCommutingYearMakeModelVINCC'sCurrent Carrier UmbrellaIn order to purchase an umbrella liability policy you must have auto liability limits of at least $250,000/$500,000/$250,000 and home/renters liability of at least $300,000. I understand that if the current liability limits on my auto and home/renters policies do not meet those minimums I will not be eligible to purchase an umbrella liability policy. How many homes do you own?This includes primary, secondary, vacation, rental and investment properties.How many home/renters claims have you made in the last 5 years?How many vehicles do you own?Do you own any of the following items? Boat/Yacht Motorcycle ATV Golf Cart Vacant Land Business Boat InformationNumber of Watercraft looking to Insure:123Primary Operator First Last Years boating experienceOther Operator InformationNameDate of BirthMarital StatusYears Experience Add RemoveList any operator in or outside the household with regular access to insured watercraft more than 12 times per yearCurrent CarrierExpiration Date MM slash DD slash YYYY Boat #1HIN #YearMakeModelBoat ValueInclude value of permanent/portable boating equipmentPurchase PriceYear PurchasedPropulsion type Inboard Outboard Inboard/Outboard Jet Non-powered Number of enginesBoat LengthHull materialTotal horsepowerExcluding trolling and kicker motorsMaximum SpeedMPHEnhanced performance modifications Add RemoveBlowers, superchargers, etc.Is boat used for racing?YesNoStorage zip codeWhere is boat stored?Primary ResidenceMarina - SlipOtherDo you own a boat trailer?YesNoValue of trailerYear purchasedMulti-OwnerNoYesMore than one owner, not in the same household Boat #2YearMakeModelBoat ValueInclude value of permanent/portable boating equipmentPurchase PriceYear PurchasedHIN #Propulsion type Inboard Outboard Inboard/Outboard Jet Non-powered Number of enginesBoat LengthHull materialTotal horsepowerExcluding trolling and kicker motorsMaximum SpeedMPHEnhanced performance modifications Add RemoveBlowers, superchargers, etc.Is boat used for racing?YesNoStorage zip codeWhere is boat stored?Primary ResidenceMarina - SlipOtherDo you own a boat trailer?YesNoValue of trailerYear purchasedMulti-OwnerYesNoMore than one owner, not in the same household Boat #3YearMakeModelBoat ValueInclude value of permanent/portable boating equipmentPurchase PriceYear PurchasedHIN #Propulsion type Inboard Outboard Inboard/Outboard Jet Non-powered Number of enginesBoat LengthHull materialTotal horsepowerExcluding trolling and kicker motorsMaximum SpeedMPHEnhanced performance modifications Add RemoveBlowers, superchargers, etc.Is boat used for racing?YesNoStorage zip codeWhere is boat stored?Primary ResidenceMarina - SlipOtherDo you own a boat trailer?YesNoValue of trailerYear purchasedMulti-OwnerYesNoMore than one owner, not in the same household Golf CartYearMakeModelPrimary Use Transportation Golfing Fuel Type Electric Gas Recreational VehicleYears RV Operating ExperienceRV TypeMotor HomeTravel TrailerMotor HomeClass AClass BClass CBus ConversionToter HomeTravel TrailerConventionalPop Up5th WheelTruck CamperYearManufacturerModel/SeriesBody StyleValue of RVLength of OwnershipGaraging Zip CodeVehicle Use < 30 Days 30-150 Days > 150 Days Primary Residence RV (Full Timer) Yes No Prior RV Insurance Yes No Prior CarrierExpiration Date MM slash DD slash YYYY Settlement Options Total Loss Replacement (new RVs up to two model years old) Actual Cash Value Agreed Value Roadside Assistance Yes No Please upload current insurance policy documents if you have them available. 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