5-MINUTE FREE QUOTE Free Quote Free Home/Auto Quote Request "*" indicates required fields 1Products2Basic Information3Policy Information4Final Comments Products Auto or Classic Car Homeowners/Condo/Renters Earthquake and/or Flood Umbrella Liability Watercraft Motorcycle RV and Toys Other Greatest concern about insurance?* Client Care Quality of Coverage Lowest Possible Price Other How did you hear about us?* Referral from family/friend Referral from a professional Web search Social media Other Do you have an electronic version (PDF) of your current coverage?* Yes No Please upload your current coverage(s)*Please minimally provide the declaration pages (first few pages of your coverage that provide the coverage limits.) This will help provide us with information necessary to shop and quote.Max. file size: 200 MB.Name* First Last Gender at birth:*MaleFemaleDate of Birth:* MM slash DD slash YYYY Are you married?* Yes No Do you live with a partner, spouse or significant other?* Yes No Physical Address* Street Address Address Line 2 City State 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 ZIP Code How long have you lived at this address?* Is your mailing address the same as your physical address?* Yes No Mailing Address* Street Address Address Line 2 City State 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 ZIP Code Phone*Email Auto Insurance QuestionsWhat insurance carrier do you currently have (if any)? DriversHow many household drivers are there?123456 or moreDriver 1 Full Name Date of Birth Age Licensed State & DL # Driver 2 Full Name Date of Birth Age Licensed State & DL # Driver 3 Full Name Date of Birth Age Licensed State & DL # Driver 4 Full Name Date of Birth Age Licensed State & DL # Driver 5 Full Name Date of Birth Age Licensed State & DL # Please list any other drivers in your household, with the same information as above.VehiclesHow many vehicles would you like to insure?123456Vehicle 1Vehicle 1 Make Model VIN # Purchase Date What is the primary use of vehicle 1?Work CommutePleasureBusinessIn Storage (not driven)How many miles is your work commute (one-way)? Vehicle 2Vehicle 2 Make Model VIN # Purchase Date What is the primary use of vehicle 2?Work CommutePleasureBusinessIn Storage (not driven)How many miles is your work commute (one-way)? Vehicle 3Vehicle 3 Make Model VIN # Purchase Date What is the primary use of vehicle 3?Work CommutePleasureBusinessIn Storage (not driven)How many miles is your work commute (one-way)? Vehicle 4Vehicle 4 Make Model VIN # Purchase Date What is the primary use of vehicle 4?Work CommutePleasureBusinessIn Storage (not driven)How many miles is your work commute (one-way)? Vehicle 5Vehicle 5 Make Model VIN # Purchase Date What is the primary use of vehicle 5?Work CommutePleasureBusinessIn Storage (not driven)How many miles is your work commute (one-way)? Additional VehiclesPlease provide the same information above about any additional vehicles.Additional InformationAre any vehicles used to transport people or goods for a fee (ie. Uber or Food Delivery)? Yes No Please select all vehicle used for the service Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Has any household driver been involved in an "at fault" OR "not at fault" incident or received any tickets in the past five years? Yes No Please select the drivers who were involved in the incident or have a ticket Driver 1 Driver 2 Driver 3 Driver 4 Driver 5 Driver 6 Have you experienced an auto claim within the past five years (including glass)? Yes No Please describe the claim(s) below, including which vehicle.MotorcycleWhat insurance carrier do you currently have (if any)? Please describe your motorcycle: Year Make Model VIN # Purchase Date MM slash DD slash YYYY Would you like to insure another motorcycle Yes No Please describe your motorcycle: Year Make Model VIN # Purchase Date MM slash DD slash YYYY Do you have any additional motorcycles to insure? Yes No Please describe any other motorcycles you would like to insure as above:Homeowners/Condo/Renters InsuranceWhat insurance carrier are you with currently (if any)? What type of home do you live in? Single Family Multi-Family (duplex, triplex, etc.) Apartment Condo Manufactured Home Other Do you own or rent? Own Rent Purchase Date:* MM slash DD slash YYYY Tell us about your home's safety features. Fire Extinguisher Deadbolt Locks Carbon Monoxide Alarm Smoke Detector Burglar Alarms Surveillance Camera Do you currently, or wish to have increased coverage for specific high valued items/collectibles (more than $5k) such as jewelry, firearms, artwork, etc.? Yes No Please describe below:Do you have any pets in your home? Yes No Please list all pets, including breed (if applicable/known):Do you operate a business out of your home or have a hobby that earns income? Examples include direct sales businesses like LuLaRoe, Etsy Shops and child care. Yes No Please describe the business you operate within your home:Have you experienced a homeowners/renters insurance claim in the past five years? Yes No Please provide detail about the insurance claim:Earthquake and/or Flood InsuranceWhat insurance carrier do you currently have (if any)? Which coverage are you interested in? Earthquake Flood Both What type of foundation does your home have? Basement Crawlspace with closed concrete perimeter Crawlspace with wood perimeter Post and Piers Slab Stilts Other How much is your home currently insured for? Umbrella Liability InsuranceWhat insurance carrier do you currently have (if any)? Please choose which coverage you are interested*We recommend choosing a limit that is at least in relation to your assets, including home and retirement accounts 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 or more Watercraft InsuranceWhat insurance carrier do you currently have (if any)? Please tell us about the boat or other watercraft you would like to insure Year Make/Model Total Horsepower Length (if applicable) Purchase Date MM slash DD slash YYYY Please list Hull ID# and Registration # Hull ID # Registration # What type of insurance does your boat have? Inboard Onboard Inboard/Onboard What is the combined value of the boat, motor, and any installed equipment? If you have a boat trailer, what is the value of it? Where is the watercraft stored? Is there a second type of watercraft you would like to insure? Yes No Please tell us about the boat or other watercraft you would like to insure Year Make/Model Total Horsepower Length (if applicable) Purchase Date MM slash DD slash YYYY Please list Hull ID# and Registration # (if applicable) Hull ID # Registration # What type of motor does your boat have? Inboard Onboard Inboard/Onboard What is the combined value of the watercraft, including motor, and any installed equipment? If you have a boat trailer, what is the value of it? Where is the watercraft stored? Are there any other types of watercraft you would like to insure? Yes No Please describe any other watercraft you are looking to insure, as above.Recreational Vehicle InsuranceWhat insurance carrier do you currently have (if any)? Please tell us about the recreational vehicle you would like to insure Year Make Model VIN # Purchase Date MM slash DD slash YYYY What is the approximate value of the recreational vehicle currently (if known)? Are there any other recreational vehicles you would like to insure? Yes No Please tell us about the recreational vehicle you would like to insure Year Make Model VIN # Purchase Date MM slash DD slash YYYY What is the value of the recreational vehicle? Are there any additional recreational vehicles you would like to insure Yes No Please describe any other recreational vehicles as aboveOther Insurance QuestionsWhat insurance carrier do you currently have (if any)? Tell us about what you are looking to insure. Final CommentsIs there anything else we should know to provide accurate quotes?ConsentBy checking this box, you allow us to contact you regarding our services and products. Any information provided will be used for internal use only. I understand that Benefit Solutions Plus, LLC is bound under regulations to keep all personal information private, and will not sell personal information to any third party company. I agreeCAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
