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Lead Form 2
Select Insurance Type
What type of insurance are you looking for?
Home Insurance
Auto Insurance
Life Insurance
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Basic Contact Info
First Name
Last Name
Date of Birth
Enter Your Address
Apt/unit# (optional)
City
State
Zip Code
Country
Select Country
United States (US)
Is that your current address?
Yes
No
Enter Your Address
Apt/unit# (optional)
City
State
Zip Code
Country
Select Country
United States (US)
Phone Number
Email
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Lets begin with qucik Questions
Do you have auto insurance?
Yes
No
What bodily injury (BI) liability limits do you need or are closest to what you currently carry?
$15,000-$30,000
$25,000-$50,000
$50,000-$100,000
$100,000-$300,000 or Higher
How many vehicles do you want to insure?
1
2
3
4+
How many drivers do you want to insure?
1
2
3
4+
Property Info
Property Type
House
Apartment
Condo
Ownership
Owned
Rent
Year of build
Square Footage
sq ft
Basic Info (Life Insurance)
Gender
Male
Female
Other
Height
cm
Weight
kgs
Smoking Status
Yes
No
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Vehicle Informations
Enter New Vehicle
Year
Model
Make
VIN (optional)
Onwership
- Select -
Owned
Leased
Financed
Primary use
- Select -
Commute
Personal
Business
Home Detail
Roof Age
Yrs
Heating Type
- Select -
Central Heating
Electric
Gas
Oil
Solar
Other
Plumbing Type
- Select -
Copper
PVC
PEX
Galvanized Steel
Mixed
Not Sure
Electrical System
- Select -
Circuit Breaker
Fuse Box
Modern Wiring
Old Wiring
Not Sure
Garage
Yes
No
Swimming Pool
Yes
No
Health Info
Do you have any pre-existing conditions?
Yes
No
Pre-existing conditions?
Diabetes
Heart Disease
Blood Pressure
Asthma
Other
Are you currently taking any medications?
Yes
No
List your medications
Any surgeries history?
Yes
No
Describe your surgery history
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Driver's Informations
Repeater Container
Enter New Driver
Full Name
Gender
- Select -
Male
Female
Marital Status
- Select -
Married
Single
Widowed
Driver's License Number
Years of driving Experience
Home Security & Safety
Do you have smoke detectors installed?
Yes
No
Do you have a burglar alarm system?
Yes
No
Do you have a fire alarm system?
Yes
No
Do you live in a gated community?
Yes
No
Lifestyle
Alcohol Consumption
- Select -
Never
Occasionally
Weekly
Daily
Any risky hobbies?
Scuba Diving
Skydiving
Racing
Mountaineering
Other
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Driving History
Any accident?
Yes
No
Any violation and ticket?
Yes
No
Claimed in last 3-5 years
Yes
No
Choose Your Coverage
Dwelling Coverage Amount
$100,000
$200,000
$300,000
$500,000
Custom Amount
Personal Property Value
$25,000
$50,000
$100,000
$200,000
Not Sure
Custom Amount
Liability Coverage
$100,000
$300,000
$500,000
$1,000,000
Deductible
$500
$1,000
$2,000
$5,000
Financial Information
What is your annual income
Less than $25,000
$25,000 – $50,000
$50,000 – $100,000
$100,000 – $200,000
$200,000+
Number of Dependents
Who depends on you?
Spouse
Children
Parents
Other
Do you have any existing life insurance policies?
Yes
No
Coverage Amount
$
Insurance Company Name
Policy Type
Term
Whole Life
Universal
Other
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Consent
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