TEST Insurance Quote

Name: ALLCHOICE Insurance
Price range: $

WHAT IS IMPORTANT TO THE CLIENT?

Before We Get Started, Let Us Know What Is Important To You When It Comes To Your Insurance

(Other Than Price) What Is Most Important When It Comes To Choosing An Insurance Carrier?(Required)

(Other Than Price) What Is Most Important When It Comes To Choosing An Insurance Advisor?(Required)

INSURED | CONTACT INFORMATION

Prospect Type(Required)

New Client

Current Client

(ONLY SELECT ONE) What Type Of Insurance Are You Looking For?(Required)

Personal

Business

Business Name (If Business Risk)(Required)

If Unsure - Please Lookup The Business On The NC Secretary Of State Website: https://www.sosnc.gov/online_services/search/by_title/_Business_Registration

Primary Contact or Insured(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Mobile Phone(Required)

Is It OK To Text You?(Required)

Gender

Male

Female

Date Of Birth

Social Security Number

**We can get preliminary pricing without your social, but we will need this information for final pricing**

Driver's License Number

Entity Type(Required)

Federal ID(Required)

Marital Status

Single

Married

Civil Union

Spouse | Partner Name

First Last

Spouse/Partner Gender

Male

Female

Spouse/Partner Date Of Birth

Spouse/Partner Social Security Number

Spouse/Partner Driver's License Number

Description Of Business (What Do You Do?)

Years In Business

Annual Revenue (If New Business = 12 Months Projected)

Number Of Employees

Annual Payroll (If New Business = 12 Months Projected)

POLICY | QUOTE INFORMATION

Personal Policy Type(s)

AUTOP

HOME

PUMBR

RENTAL PROPERTY

What type of insurance can we help you with

Is This A Trucking Exposure?

Yes

Department Of Transportation Number (DOT #)

Motor Carrier Number (MC#)

Business Policy Type(s)

What type of insurance can we help you with

Personal Auto Policy Information

Current Coverage

Yes

Do you have current insurance coverage?

Current Carrier

Who is your current carrier?

Effective Date

Bodily Injury Liability

Property Damage

Medical Payment

Driver Information

Number of Drivers (Other than Insured & Spouse / Partner)

Personal Driver 1

First Last

Date of Birth (Driver 1)

Driver's License Number (Driver 1)

Personal Driver 2

First Last

Date of Birth (Driver 2)

Driver's License Number (Driver 2)

Personal Driver 3

First Last

Date of Birth (Driver 3)

Driver's License Number (Driver 3)

Personal Vehicle Information & Vehicle Level Coverage

Number of Vehicles

Vehicle 1 Year

Vehicle 1 Make

Vehicle 1 Model

Vehicle 1 VIN

Other Than Collision | Comprehensive Coverage

Collision Coverage

Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 / $1,500

Road Service / Towing & Labor

No Coverage

$25

$50

$100

Vehicle 2 Year

Vehicle 2 Make

Vehicle 2 Model

Vehicle 2 VIN

Other Than Collision | Comprehensive Coverage

Collision Coverage

Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 / $1,500

Road Service / Towing & Labor

No Coverage

$25

$50

$100

Vehicle 3 Year

Vehicle 3 Make

Vehicle 3 Model

Vehicle 3 VIN

Other Than Collision | Comprehensive Coverage

Collision Coverage

Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 / $1,500

Road Service / Towing & Labor

No Coverage

$25

$50

$100

Vehicle 4 Year

Vehicle 4 Make

Vehicle 4 Model

Vehicle 4 VIN

Other Than Collision | Comprehensive Coverage

Collision Coverage

Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 / $1,500

Road Service / Towing & Labor

No Coverage

$25

$50

$100

Enter Misc Auto Information

Upload Any Auto Insurance Files You May Have

Drop files here or

Max. file size: 12 GB.

Business Auto Policy Information

Are All Vehicles Titled To The Named Insured?(Required)

Yes

Vehicles Must Be Titled How They Are Insured

How Are The Vehicles Titled?(Required)

Current Commercial Auto Coverage(Required)

Yes

Do you have current insurance coverage?

Current Carrier

Who is your current carrier?

Effective Date

Combined Single Limit

UnInsured/UnderInsured Combined Single Limit

Medical Payment

Additional Policy Level Coverage(s)

Hired Auto

Non-Owned Auto

Commercial Driver Information

Number of Commercial Drivers

Commercial Driver 1

First Last

Date of Birth (CD 1)

Driver's License Number (CD 1)

Commercial Driver 2

First Last

Date of Birth (CD 2)

Driver's License Number (CD 2)

Commercial Driver 3

First Last

Date of Birth (CD 3)

Driver's License Number (CD 3)

Commercial Driver 4

First Last

Date of Birth (CD 4)

Driver's License Number (CD 4)

Vehicle Information & Vehicle Level Coverage

Number of Commercial Vehicles

Vehicle 1 Year

Vehicle 1 Make

Vehicle 1 Model

Vehicle 1 VIN

Vehicle 1 Original Cost New

Vehicle 1 Stated Value

Vehicle 1 GVW

Radius Of Operations

Other Than Collision | Comprehensive Coverage

Collision Coverage

Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 / $1,500

Road Service / Towing & Labor

No Coverage

$25

$50

$100

Vehicle 2 Year

Vehicle 2 Make

Vehicle 2 Model

Vehicle 2 VIN

Vehicle 2 Original Cost New

Vehicle 2 Stated Value

Vehicle 2 GVW

Radius Of Operations

Other Than Collision | Comprehensive Coverage

Collision Coverage

Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 / $1,500

Road Service / Towing & Labor

No Coverage

$25

$50

$100

Vehicle 3 Year

Vehicle 3 Make

Vehicle 3 Model

Vehicle 3 VIN

Vehicle 3 Original Cost New

Vehicle 3 Stated Value

Vehicle 3 GVW

Radius Of Operations

Other Than Collision | Comprehensive Coverage

Collision Coverage

Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 / $1,500

Road Service / Towing & Labor

No Coverage

$25

$50

$100

Vehicle 4 Year

Vehicle 4 Make

Vehicle 4 Model

Vehicle 4 VIN

Vehicle 4 Original Cost New

Vehicle 4 Stated Value

Vehicle 4 GVW

Radius Of Operations

Other Than Collision | Comprehensive Coverage

Collision Coverage

Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 / $1,500

Road Service / Towing & Labor

No Coverage

$25

$50

$100

Enter Misc Auto Information

Upload Any Auto Insurance Files You May Have

Drop files here or

Max. file size: 12 GB.

Trucking Related Coverages

Do You Need Trailer Interchange Coverage?

Yes

Do You Need Primary Liability Coverage?

Yes

Do You Need Non-Trucking Liability (Bobtail)?

Yes

Do You Need Cargo Coverage?

Yes

How Much Cargo Coverage Do You Need?

Do You Need Reefer Coverage?

Yes

How Many Types Of Goods Are Hauled?

Type Of Goods - Description

Percentage Of Total Goods

Type Of Goods - Description

Percentage Of Total Goods

Type Of Goods - Description

Percentage Of Total Goods

Type Of Goods - Description

Percentage Of Total Goods

Home Information

New Purchase Or Existing Home

New Home Purchase

Existing Home

Closing Date

Loan Officer Name

First Last

Loan Officer Email

Loan Officer Mobile Phone

Realtor Name

First Last

Realtor Email

Realtor Mobile Phone

Closing Attorney Name

First Last

Closing Attorney Email

Closing Attorney Mobile Phone

Previous Address

Street Address City State ZIP Code

Effective Date

Current Carrier

Purchase Price

What Type Of Home?

Does The HOA Cover The Shell?

Yes

New Construction

Yes

Year Built

Is House Older Than 20 Years

Yes

If House Older Than 20 Years - Year Of Roof Update

If House Older Than 20 Years - Year Of Electric Update

If House Older Than 20 Years - Year Of Plumbing Update

If House Older Than 20 Years - Year Of HVAC Update

Construction Of Home

Frame

Brick Veneer

Log

Other

Square Footage

Number Of Stories

Dimensions

Please enter in Feet (ex 20ft X 60ft)

Foundation Type

Homeowner's Coverage Information

Dwelling Coverage Amount

Deductible

$1,000

$1,500

$2,500

$5,000

Personal Liability

$1,000,000

$500,000

$300,000

Medical Payments To Others

$1,000

$2,000

$5,000

Enter Misc Homeowner's Info

Upload Any Homeowner's Files You May Have

Drop files here or

Max. file size: 12 GB.

Business Owners Information

Effective Date

Current Coverage

Yes

Current Carrier

BOP Coverage Types

General Liability Only (GL)

GL + Building Coverage

GL + Business Contents

GL + Building + Business Contents

Number of Location(s)/Building(s)

Same As Mailing Addres

Main Address (Other Than Mailing)

Add'l Locations (Other Than Primary)

Enter # of Locations/Buildings (if more than 2 please enter information in "Multiple Location | Building Info" Section

Primary Location Address

Street Address City State ZIP Code

Multiple Location | Building Info

Enter Any Address Info | Coverage Info as notes

Business Owners Coverage Information

General Liability Limits

$1,000,000 | $2,000,000

$500,000 | $1,000,000

$300,000 | $600,000

Building Coverage

Business Personal Property Coverage

Optional Coverage (Select All That Apply)

Cyber Liability

Employment Practices Liability

Professional Liability

Enter Misc BOP | CPKG Info

Upload Any BOP | CPKG Files

Drop files here or

Max. file size: 12 GB.

Workers Compensation Information

Effective Date

Current Coverage

Yes

Current Carrier

Number Of Class Codes

Class Code (Main)

If you don't have/know the Code - please enter description

Class Code Payroll (Main)

Class Code (2)

If you don't have/know the Code - please enter description

Class Code Payroll (2)

Class Code (3)

If you don't have/know the Code - please enter description

Class Code Payroll (3)

Workers Compensation Coverage Information

Workers Compensation Limit

$1,000,000 | $1,000,000 | $1,000,000

$500,000 | $500,000 | $500,000

$100,000 | $500,000 | $100,000

Enter Misc Workers Compensation Information

Upload Misc Workers Compensation Files

Drop files here or

Max. file size: 12 GB.

Personal Umbrella Coverage

Effective Date

Current Coverage

Yes

Current Carrier

Personal Umbrella Limit

Enter Misc Personal Umbrella Information

Enter any misc info (ex. Underlying Coverage(s) and rating info not already entered)

Upload Personal Umbrella Files

Drop files here or

Max. file size: 12 GB.

Commercial Umbrella Coverage

Effective Date

Current Coverage

Yes

Current Carrier

Commercial Umbrella Limit

Enter Misc Commercial Umbrella Information

Enter any misc info (ex. Underlying Coverage(s) and rating info not already entered)

Habitational | Rental Property Information

Effective Date

Current Coverage

Yes

Current Carrier

Habitational | Rental Property Coverage

Number of Location(s) | Building(s)

More Than 1

If More than 1 location or building - please enter information in "Enter More Location Information" Section or upload current Dec Pages in the Upload File Section

Location Address

Street Address City State ZIP Code

Building Coverage

Year Built

Square Footage

Number of Families Per Building

Construction

Number of Stories

Sprinklered

Yes

Enter More Location Information

Enter Misc Habitational | Rental Property Information

Upload Habitational | Rental Property Files

Drop files here or

Max. file size: 12 GB.

Upload Bond | Surety Misc Files

Drop files here or

Max. file size: 12 GB.

Lead Source [Producer Completed]

How did the prospect became aware of ALLCHOICE Insurance? Did they learn about ALLCHOICE through Agent Activity? (Agent Activity) Was it through a referral from someone they know? (Referral) Or are they already a Current Client of ALLCHOICE Insurance? (Current Client)"(Required)

Agent Activity

Referral

Current Client

Agent Activity - Lead Source

Provide details about the agent's interaction with prospect?(Required)

Referral - Lead Source

Who referred prospect to ALLCHOICE Insurance?(Required)

Current Client - Lead Source

What motivated client to revisit our services or seek additional assistance?(Required)

Disclosure Statement

By submitting this request, you agree to receive communication(s) from ALLCHOICE, Inc. via Phone, Text, SMS, Email, Voicemail, or any other form of communication that may be deemed as beneficial.

We use the information you provide as well as information from other sources, such as your driving record, claims, and credit histories, to calculate a price for your insurance.

Confirmation

Please review your information to ensure all fields are filled before submitting.(Required)

I confirm that all the information provided above is accurate and complete.

Select The Best Opportunity Stage For This Lead To Start?(Required)

New Lead

Out For Quote