Request for Quote

Request for Insurance Proposal

We just need a little more info to get your proposal put together. The more information you can give, the better we can customize your policies to protect the things that are important to you. Our goal is to keep a bad day from becoming a bad decade. If you have any questions, give us a call at 972-329-4811.
"In connection with this application for insurance, we may review your credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third party in connection with the development of your insurance score." This is not a "hard check" and will not affect your credit score Do we have your permission to quote?

YesNo
"You will be receiving a Privacy Notice that gives you the choice of opting out of allowing Farmers to share your consumer report information, such as your credit-based insurance score or loss history, among our affiliates. In the interim, may we use the consumer report information we currently have on file for you for this specific transaction? You will still be able to opt out of any future sharing."

YesNo
We will need your permission to quote before we can put together an insurance propoal. If you have questions regarding the quoting process and the permissions we have requested, please call or text our office at 972-329-4811
First Name*
Last Name*
E-Mail*
Email
Primary Phone Number*
What is the best way for our office to reach you with follow up questions or to schedule your proposal review?

PhoneTextEmail
Please upload a copy of your current home and auto coverages. We would like to make sure there are no gaps in your current coverage and if there are, that we are addressing them in our proposal. A picture or screenshot are fine.

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Cancelof
Age
Date of Birth*

MonthDayYear
Month, Day, Year
SSN
This helps us make sure its the correct you when we pull your insurance scores. Your credit report will be pulled but it is not a "hard" check and will not affect your credit score.
Drivers License Number*
Drivers License Issuing State*
Farmers offers a discounts for various lines of work or fields of study, What is your occupation? If retired, what was your occupation prior to retirement?
Do you have a College Degree?

YesNo
What Degree do you have? And in what field of study?
EX: Bachelor of Science in Chemistry, BA in Communications, etc.
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address the same as your physical address?

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status

MarriedSingle/Separated/Divorced
Spouse Info
Spouse's Name

First NameLast Name
Spouse's E-Mail
Email
Spouse's Phone Number
Spouse's Date of Birth

MonthDayYear
Date
Spouse's SSN
Spouse's Drivers License Number
If you don't have your spouse's DL number, that's okay. If it is issued in TX we should be able to look it up. If it is outside of TX, we will need you to send over the DL# as soon as you can.
Drivers License Issuing State
What is your spouse's occupation? if they are retired, what was their occupation prior to retirement?
Auto Info
Do You Currently Have Auto Insurance?

YesNo
Who is your current auto insurance carrier?
Geico, Allstate, Traveler's, Progressive, AAA, etc.
About how long have you been with them?
Roughly how much are you paying for your auto insurance right now?
EX: $200/month or $1,000 for 6 months, $2,000 for a year
How many vehicles are you looking to insure?

123456more than 6
Vehicle #1 VIN -or- Year, Make, Model
Vehicle #1 - Where is the vehicle parked at night?

GarageCarportOff-StreetOn-Street
Vehicle #1 - About how many miles do you put on this vehicle annually?
Vehicle #1 - What year did you purchase this vehicle?
Vehicle #1 - Do you own, finance, or lease this vehicle?

OwnedFinancedLeased
Vehicle #1 - Who is the Registered Owner of the Vehicle?
Vehicle #1 - Finance/Lease Info
Name of lender, loan number, phone number, address, any other info. We will need this info in order to bind the policy, but if you need to get back to us with it, that is fine.
Vehicle #2 VIN -or- Year, Make, Model
Vehicle #2 - Where is the vehicle parked at night?

GarageCarportOff-StreetOn-Street
Vehicle #2 - About how many miles do you put on this vehicle annually?
Vehicle #2 - What year did you purchase this vehicle?
Vehicle #2 - Do you own, finance, or lease this vehicle?

OwnedFinancedLeased
Vehicle #2 - Who is the registered owner of this vehicle?
Vehicle #2 - Finance/Lease Info
Name of lender, loan number, phone number, address, any other info. We will need this info in order to bind the policy, but if you need to get back to us with it, that is fine.
Vehicle #3 VIN -or- Year, Make, Model
Vehicle #3 - Where is the vehicle parked at night?

GarageCarportOff-StreetOn-Street
Vehicle #3 - About how many miles do you put on this vehicle annually?
Vehicle #3 - What year did you purchase this vehicle?
Vehicle #3 - Do you own, finance, or lease this vehicle?

OwnedFinancedLeased
Vehicle #3 - Who is the registered owner of this vehicle?
Vehicle #3 - Finance/Lease Info
Name of lender, loan number, phone number, address, any other info. We will need this info in order to bind the policy, but if you need to get back to us with it, that is fine.
Vehicle #4 VIN -or- Year, Make, Model
Vehicle #4 - Where is the vehicle parked at night?

GarageCarportOff-StreetOn-Street
Vehicle #4 - About how many miles do you put on this vehicle annually?
Vehicle #4 - What year did you purchase this vehicle?
Vehicle #4 - Do you own, finance, or lease this vehicle?

OwnedFinancedLeased
Vehicle #4 - Who is the registered owner of this vehicle?
Vehicle #4 - Finance/Lease Info
Name of lender, loan number, phone number, address, any other info. We will need this info in order to bind the policy, but if you need to get back to us with it, that is fine.
Vehicle #5 VIN -or- Year, Make, Model
Vehicle #5 - Where is the vehicle parked at night?

GarageCarportOff-StreetOn-Street
Vehicle #5 - About how many miles do you put on this vehicle annually?
Vehicle #5 - What year did you purchase this vehicle?
Vehicle #5 - Do you own, finance, or lease this vehicle?

OwnedFinancedLeased
Vehicle #5 - Who is the registered owner of the vehicle?
Vehicle #5 - Finance/Lease Info
Name of lender, loan number, phone number, address, any other info. We will need this info in order to bind the policy, but if you need to get back to us with it, that is fine.
Vehicle #6 VIN -or- Year, Make, Model
Vehicle #6 - Where is the vehicle parked at night?

GarageCarportOff-StreetOn-Street
Vehicle #6 - About how many miles do you put on this vehicle annually?
Vehicle #6 - What year did you purchased this vehicle?
Vehicle #6 - Do you own, finance, or lease this vehicle?

OwnedFinancedLeased
Vehicle #6 - Who is the registered owner of this vehicle?
Vehicle #6 - Finance/Lease Info
Name of lender, loan number, phone number, address, any other info. We will need this info in order to bind the policy, but if you need to get back to us with it, that is fine.
list any additional vehicles VIN numbers -or- Year, Make, Model
Do you or anyone in your household use the vehicle (any of the vehicles) for ridesharing or local delivery such as Uber, Lyft, pizza delivery, or DoorDash?
Rideshare? (Uber or Lyft, with riders)

YesNo
Local Delivery? (Pizza Delivery, Amazon Flex, Uber Eats, Door Dash, Favor, Etc.)

YesNo
How many hours per week is the vehicle used for rideshare or local delivery
Which vehicles are used for rideshare or local delivery?
Additional Drivers

Children, family, roommates
Do you have any additional drivers, not including your spouse, that live with you such as kids, family members, or roommates?

YesNo
Our system pulls every driver at the same address in because they assume if they live with you there is a chance they may drive your car. If you do not want to include someone that lives with you on your policy, we can manually exclude them. That does mean if they were to ever borrow your car for any reason, they would not have any coverage if something were to happen.
Would you like to exclude anyone from your policies? (if you have grown children who no longer live with you, please list them as "out of household" so we can mark them as such.)
First & Last Name of Exclusions or Out of Household
How many additional drivers are in your household?

12345
Additional Driver #1

First NameLast Name
Date of Birth

MonthDayYear
Date
DL #
Additional Driver #2

First NameLast Name
Date of Birth

MonthDayYear
Date
DL #
Additional Driver #3

First NameLast Name
Date of Birth

MonthDayYear
Date
DL #
Additional Driver #4

First NameLast Name
Date of Birth

MonthDayYear
Date
DL #
Additional Driver #5

First NameLast Name
Date of Birth

MonthDayYear
Date
DL #
Homeowner/Renters Info
We have great discounts for bundling your home and auto policies, up to 20% saving on both policies. If we can get some quick information on your home, we can make sure you know what your max savings are.
Do you own or rent your home?

Currently OwnCurrently RentCurrently Buying
How long have you lived at this address?
How many people reside in your home?
Do you rent out your home or a portion of your home?

YesNo
How many days per year do you rent out your home or a portion of your home?

Less than 30 days per yearMore than 30 days per year
Who is the current carrier of you homeowners insurance?
How long have you been with them?
In order to keep your home buying team appraised of your insurance policies, we ask for the contact info of your realtor and mortgage loan officer. They will each need information from us regarding your policies in order for your closing to happen smoothly and as scheduled.
Who is your realtor?
Realtor Phone #
Please enter a valid phone number.
Realtor Email
example@example.com
Mortgage Loan Officer (MLO) Name
Name
MLO Phone #
Please enter a valid phone number.
MLO Email
example@example.com
Expected Closing Date

MonthDayYear
Date
Loan Amount
Year home was built
Square Footage
What kind of materials are the outside walls of your home made of?
Brick, wood siding, stone, stucco/concrete, etc
What kind of material is the roof made of? (See picture below)
When was the roof last replaced?
year
Does the home have storm shutters able to withstand 120 MPH wind?

YesNo
Does the home have reinforced glass windows able to withstand 120 MPH wind?

YesNo
Does the home have a security system?

YesNo
Is it monitored by a service or self monitored?

Alarm Company MonitoredSelf Monitored
Does the home have a fire alarm system?

YesNo
Is it monitored by a service or self monitored?

Alarm Company MonitoredSelf Monitored
Does the home have an automatic fire suppression sprinkler system?

YesNo
Does the home have a wifi enabled smart thermostat?

YesNo
Does the home have galvanized or polybutylene plumbing?

YesNoI'm not sure.
Is there a trampoline on the property?

YesNo
Does the trampoline have walls/netting?

YesNo
Is there a pool on the property?

YesNo
Is the pool/yard fully fenced?

YesNo
Does the home have an attached garage?

YesNo
How many cars does it hold?
1 car, 2 car, 4 car, etc
Is your home currently financed?

YesNo
We will need to get your lender info in order to move forward with the policy. We need the name of the bank or loan company, the loan number, their mailing address, and phone number. If you do not have that on hand, you can submit the form without and email the details to sales@ottinsurance.agency.
Lender Name
Lender Phone #
Please enter a valid phone number.
Lender Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Loan Number
When was the last time your had a mortgage review or considered a refinance?
Do You Have a Home Warranty?

YesNo
Who is your warranty with?
When does your warranty expire?
Name of Apartment Complex or Management Company (who needs to be listed as the additional interest on renters policy)
Email of Complex or Management Company (to send your evidence of insurance to)
example@example.com
Phone Number of Complex or Management Company
Please enter a valid phone number.
Address of Complex or Management Company

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are You Currently Looking to Buy or Sell a Home?

YesNo
Do you need a realtor recommendation?

YesNo
Misc Questions
Do you have any pets?

YesNo
Name, Type, Breed, Age of pets
Ex: Cowboy, Dog, Hound, 9 y.o.
Do you have Life Insurance outside of work?

YesNo
Who's the carrier?
Details about type, limit, expiration of life policy
Do you own any rental properties?

YesNo
If so, give some details.
Any 'toys'? (motorcycles, ATVs, Jetskis RVs)

YesNo
If so, give some details.
Do you have Umbrella Insurance?

YesNo
What is the limit?
What steps have you taken to prepare for retirement?
When was the last time you reviewed your health insurance plan?
Which Medicare plan are you on?

Plan APlan B
Are you a Small Business owner?

YesNo
Tell me a little about your business.
What types of insurance are you interested in getting a quote for today?

HomeAutoUmbrellaLifeSpecialty (RV, Motorcycle, Watercraft)PetCommercial
Any Additional Notes we should consider when building your policies?
Furs, collectables, etc
Should be Empty:

Request for Insurance Proposal

Spouse Info

Auto Info

Additional Drivers

Homeowner/Renters Info

Misc Questions