Start Your Quotes (GF Version) – Bailey Family Insurance

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Step 1 of 46

About You

Let's gather some initial info before we talk about insurance...

Name

First Last

Date of Birth

MM slash DD slash YYYY

How did you hear about us?

Referred by someone

Google / Online Search

Social Media

I was contacted by Bailey Family Insurance

Other

GREAT....we LOVE referrals! Who referred you to us?

Can you provide some details for us?

About You

Let's gather some initial info before we talk about insurance...

Email Address

Mobile Phone

Is it ok if we text you?

Yes, texting makes things quick & easy!

No, I don't like texting.

What is your current home address?

Street Address City State ZIP Code

Have you moved within the past five years?

Yes

What was your previous address?

Street Address City State ZIP Code

About You

Let's gather some initial info before we talk about insurance...

What is your relationship status?

Single

Married

Domestic Partner

Spouse's Information

Name

First Last

Date of Birth

MM slash DD slash YYYY

Email Address

Mobile Phone

Permission to text?

Yes, texting makes things quick & easy!

No, I don't like texting.

Domestic Partner's Information

Name

First Last

Date of Birth

MM slash DD slash YYYY

Email Address

Mobile Phone

Permission to text?

Yes, texting makes things quick & easy!

No, I don't like texting.

And now on to the fun stuff...

What kind of insurance proposal can we prepare for you today?

Auto

Home

Renters

Landlord Dwelling

Mobile/Manufactured Home

Motorcycle/ATV

Motorhome/Camper

Boat/Watercraft

Personal Liability Umbrella

Life Insurance

Other

Select all that apply

Auto Insurance

When would you like your new auto insurance policy to start?

MM slash DD slash YYYY

Auto Insurance

Your Driver's License Number:

Your Driver's License State:

Spouse's Driver's License Number:

Spouse's Driver's License State:

Domestic Partner's Driver's License Number:

Domestic Partner's Driver's License State:

Are there additional drivers in your household?

Yes

Additional Household Drivers:

Driver Name

Relationship (Child, Parent, etc.)

Date of Birth

Driver's License Number

Driver's License State

Auto Insurance

Do you currently have auto insurance?

Yes

What is the name of your current auto insurance company?

If possible, please upload a copy of your current auto insurance policy here:

Max. file size: 98 MB.

Auto Insurance

Liability Coverage

Model

VIN

Comprehensive

Collision

Rental Reimbursement

Roadside Assistance

Auto Insurance

Telematics

Some of our auto insurance carriers offer a Telematics program. These programs allow the insurance company to use smartphone technology or a device that plugs directly into your vehicle to monitor certain driving habits in order to qualify you for discounts as high as 30%.

If available, would you like to enroll in telematics?

Yes

Please feel free to provide any additional information you think we may need in order to provide the most accurate auto insurance proposal for you.

Homeowners Insurance

When would you like your new homeowner insurance policy to start?

MM slash DD slash YYYY

Is this for a new home purchase?

Yes

Is there a mortgagee / lienholder?

Yes

Will this policy be paid via mortgage escrow?

Yes

Mortgagee / Lienholder Name:

Is the property address the same as your previously entered home address?

Yes

Please enter the property address:

Street Address City State ZIP Code

If you have a current homeowners insurance policy on this house, please upload a copy here.

Max. file size: 98 MB.

Homeowners Insurance

How will this home be used?

Primary Residence

Secondary Residence

Seasonal Residence

What year was the home built?

Please select the foundation type:

Specify "Other" foundation type:

% of basement that is finished:

Please enter a number from 0 to 100.

Homeowners Insurance

Home Square Footage (living space):

Number of Stories (not incl. basement):

Please enter a number from 1 to 4.

Main Exterior Wall Material:

Please Specify Exterior Wall Material:

When was the roof last updated?

What type of roof is on the house?

Please Specify the Roof Type:

Homeowners Insurance

What is the primary heat source?

How many bathrooms are in the house?

Please enter a number from 1 to 20.

Is there a swimming pool on the premises?

Yes

Is the pool fenced with a locking gate?

Yes

Is there a diving board or slide?

Yes

Is there a trampoline on the premises?

Yes

Is the trampoline fenced?

Yes

Homeowners Insurance

Desired amount of dwelling coverage:

You can skip this if you aren't sure.

Desired Policy Deductible:

The deductible is the amount you will pay if you have a claim.

Please specify your desired deductible:

Please select all security devices that are present:

Deadbolt Locks

Fire Extinguisher

Local Smoke/Fire Alarm

Local Burglar Alarm

Monitored Fire Alarm

Monitored Burglar Alarm

Automatic Water Sensors

Please feel free to provide any additional information you think we may need in order to provide the most accurate homeowner insurance proposal for you.

Renters Insurance

When would you like your new renters insurance policy to start?

MM slash DD slash YYYY

Type of Rental Dwelling:

Name of the Apartment Complex:

Is the address the same as your previously entered home address?

Yes

What is the correct property address?

Street Address City State ZIP Code

If you have a current renters insurance policy, please upload a copy here.

Max. file size: 98 MB.

Renters Insurance

Desired amount of Personal Property Coverage:

Please specify your desired amount of Personal Property Coverage:

This is coverage for all of your personal belongings (clothing, furniture, electronics, dishes, etc.)

Desired amount of Personal Liability Coverage:

Please check with your landlord or property manager. Your rental agreement may include a required minimum amount of personal liability coverage.

Please feel free to provide any additional information you think we may need in order to provide the most accurate renters insurance proposal for you.

Landlord Dwelling

When would you like your new Landlord Dwelling insurance policy to start?

MM slash DD slash YYYY

Is there a mortgagee / lienholder?

Yes

Will this policy be paid via mortgage escrow?

Yes

Mortgagee / Lienholder Name:

Please enter the property address:

Street Address City State ZIP Code

If you have a current landlord dwelling insurance policy on this house, please upload a copy here.

Max. file size: 98 MB.

Landlord Dwelling

What year was the home built?

Please select the foundation type:

Specify "Other" foundation type:

% of basement that is finished:

Please enter a number from 0 to 100.

Landlord Dwelling

Home Square Footage (living space):

Number of Stories (not incl. basement):

Please enter a number from 1 to 4.

Main Exterior Wall Material:

Please Specify Exterior Wall Material:

When was the roof last updated?

What type of roof is on the house?

Please Specify the Roof Type:

Landlord Dwelling

What is the primary heat source?

How many bathrooms are in the house?

Please enter a number from 1 to 20.

Is there a swimming pool on the premises?

Yes

Is the pool fenced with a locking gate?

Yes

Is there a diving board or slide?

Yes

Is there a trampoline on the premises?

Yes

Is the trampoline fenced?

Yes

Landlord Dwelling

Desired amount of dwelling coverage:

You can skip this if you aren't sure.

Desired Policy Deductible:

The deductible is the amount you will pay if you have a claim.

Please specify your desired deductible:

Please select all security devices that are present:

Deadbolt Locks

Fire Extinguisher

Local Smoke/Fire Alarm

Local Burglar Alarm

Monitored Fire Alarm

Monitored Burglar Alarm

Automatic Water Sensors

Please feel free to provide any additional information you think we may need in order to provide the most accurate homeowner insurance proposal for you.

Mobile / Manufactured Home

When would you like this new policy to start?

MM slash DD slash YYYY

Is this for a new home purchase?

Yes

Is there a mortgagee / lienholder?

Yes

Will this policy be paid via mortgage escrow?

Yes

Mortgagee / Lienholder Name:

Is the property address the same as your previously entered home address?

Desired amount of dwelling coverage:

You can skip this if you aren't sure.

Desired Policy Deductible:

The deductible is the amount you will pay if you have a claim.

Please specify your desired deductible:

Please select all security devices that are present:

Deadbolt Locks

Fire Extinguisher

Local Smoke/Fire Alarm

Local Burglar Alarm

Monitored Fire Alarm

Monitored Burglar Alarm

Automatic Water Sensors

Please feel free to provide any additional information you think we may need in order to provide the most accurate homeowner insurance proposal for you.

Motorcycle / ATV

When would you like this new insurance policy to start?

MM slash DD slash YYYY

How many years of experience do you have operating motorcycles or ATV's?

If you have a current motorcycle or ATV policy, please upload a copy here.

Max. file size: 98 MB.

Motorcycle / ATV

Your Driver's License Number:

Your Driver's License State:

Spouse's Driver's License Number:

Spouse's Driver's License State:

Domestic Partner's Driver's License Number:

Domestic Partner's Driver's License State:

Are there additional drivers in your household?

Yes

Additional Household Drivers:

Driver Name

Relationship (Child, Parent, etc.)

Date of Birth

Driver's License Number

Driver's License State

Motorcycle / ATV

List all Motorcycles/ATV's below:

Year

Make

Model

VIN (if available)

Collision Deductible

Comprehensive Deductible

Please feel free to provide any additional information you think we may need in order to provide the most accurate auto insurance proposal for you.

Motorhome / Camper

When would you like this new insurance policy to start?

MM slash DD slash YYYY

Your Driver's License Number:

Your Driver's License State:

Spouse's Driver's License Number:

Spouse's Driver's License State:

Domestic Partner's Driver's License Number:

Domestic Partner's Driver's License State:

Are there additional drivers in your household?

Yes

Additional Household Drivers:

Driver Name

Relationship (Child, Parent, etc.)

Date of Birth

Driver's License Number

Driver's License State

Motorhome / Camper

List all Motorhomes/Campers below:

Year

Make

Model

VIN (if available)

Collision Deductible

Comprehensive Deductible

Storage location when not in use:

Please feel free to provide any additional information you think we may need in order to provide the most accurate Motorhome/Camper insurance proposal for you.

Boat / Watercraft

When would you like this new insurance policy to start?

MM slash DD slash YYYY

How many years of experience do you have operating watercraft?

If you have a current Boat/Watercraft policy, please upload a copy here.

Max. file size: 98 MB.

Boat / Watercraft

Your Driver's License Number:

Your Driver's License State:

Spouse's Driver's License Number:

Spouse's Driver's License State:

Domestic Partner's Driver's License Number:

Domestic Partner's Driver's License State:

Are there additional operators in your household?

Yes

Additional Household Operators:

Driver Name

Relationship (Child, Parent, etc.)

Date of Birth

Driver's License Number

Driver's License State

Boat / Watercraft

List all Boats/Watercrafts below:

Year

Make

Model

VIN (if available)

Collision Deductible

Comprehensive Deductible

Please feel free to provide any additional information you think we may need in order to provide the most accurate Boat/Watercraft insurance proposal for you.

Personal Liability Umbrella

When would you like this new policy to start?

MM slash DD slash YYYY

Desired amount of liability coverage

If you have a current Personal Liability Umbrella policy, please upload a copy here.

Max. file size: 98 MB.

Personal Liability Umbrella

Number of Household Vehicles

Number of Owner-Occupied Homes

Number of Rental Units Owned

Number of Boats/Watercrafts

Number of Household Members Under the age of 25

Number of Household Off-Road Vehicles

Number of Household Motorcycles

Personal Liability Umbrella

Is there a business operated on the residence premises?

Yes

Description of Business

Is any farming conducted on the residence premises?

Yes

Description of farming operations on residence premises

Does any member of the household hold an elected office or a high-profile position?

Yes

Please describe the elected office or high-profile position

Please feel free to provide any additional information you think we may need in order to provide the most accurate Personal Liability Umbrella proposal for you.

Life Insurance

How much life insurance coverage do you need?

What type of life insurance do you want?

Term Life

Whole Life

Universal Life

Burial Policy

How long would you like your Term Life policy to last?

10 Years

15 years

20 Years

25 Years

30 Years

Life Insurance

Sex:

Male

Female

Weight (lbs.)

Height (in inches)

ex. 5'10" = 70"

Life Insurance

Do you use any kind of nicotine or tobacco products?

Yes

Please describe your nicotine/tobacco usage:

Have you ever had a life insurance application declined?

Yes

Please provide details regarding your previous life insurance declination:

Life Insurance

Please select all medical conditions that apply:

Cancer

Heart Disease / Heart Attack

Asthma

Sleep Apnea

Stroke

COPD / Emphysema

Crohn's Disease

Lupus

Other

Please provide details regarding your Cancer:

Please provide details regarding your Heart Disease / Heart Attack:

Please provide details regarding your Asthma:

Please provide details regarding your Sleep Apnea:

Please provide details regarding your Stroke:

Please provide details regarding your COPD / Emphysema:

Please provide details regarding your Crohn's Disease:

Please provide details regarding your Lupus:

Please provide details regarding your other medical conditions:

Life Insurance

Do you take any prescription medications?

Yes

Please list all prescription medications you are currently taking

Medication

Dosage

Frequency

Condition Treated

Are both of your biological parents still living?

Yes

Did either of them die prior to age 60 due to a heart-related condition?

Yes

Please provide any additional information you think we may need in order to provide the most accurate Life Insurance proposal for you.

Tell us what you're looking for...

Please provide some details below and we'll see what we can find for you!

One last question...

How would like to receive your proposal?

Phone Call

Text Message

Postal Mail

Please verify your mailing address:

Street Address City State ZIP Code

All done!

Once you're finished, go ahead and click "Submit" and we'll get to work for you as quickly as possible.

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