Auto Quote Questionnaire (Website Link)

Name*

First NameLast Name

Email: *

example@example.com

Phone Number*

Please enter a valid phone number.

Date of Birth*

Drivers License Number*

What is your occupation?*

What date would you like this policy to start?*

Physical Address where you live and keep your vehicle(s)*

Street Address

CityState / Province

Postal / Zip Code

Do you own or rent here?*

How long have you lived here?*

What is your most recent prior address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Different mailing address?*

Mailing Address*

Street Address

CityState / Province

Postal / Zip Code

Are you married or single*

Spouse's Name*

First NameLast Name

Spouse's Date of Birth*

Spouse's Drivers License Number*

Spouse's Occupation*

Spouse's Phone Number*

Please enter a valid phone number.

Spouse's Email*

example@example.com

For your vehicles, who drives which, their distance one way to work/school, and how long have you owned that vehicle?

Driver & Vehicle Details*

Who is your loan or lease through?*

If any vehicles are owned or co-owned by anyone other than you or your spouse, please list them below, and the name and relationship of the other owner/co-owner:

Leave blank if all vehicles owned and titled in your or your spouse's name

Please list and describe any accidents or tickets for any household members within the last 5 years. Please indicate the date, driver involved, and what happened. For all speeding tickets, please indicate driver and how fast over. (This information is what we will use to rate the policy, and if it is inaccurate it may cause a rate change after binding)*

Name, Date of Birth, for anyone else in your household (regardless of age or if they drive any of your vehicles or not) other than those listed above with the vehicles:*

If you have roommates - please indicate their name (DOB if you know it) and indicate if they should be completely excluded from driving and coverage, or included for coverage on your policy

Do you have current auto insurance today?*

Who is your current auto insurance carrier?*

Who is your current auto carrier?*

How many years have you been with your current auto insurance company?*

Please Upload A Copy of Your Existing Auto Policy Declaration (NOT ID CARD):*

*THIS IS A HUGE HELP as we can do a policy review of your existing coverage and confirm if is appropriate for your current situation.

What is your renewal or expiration date of your current policy?*

You can put "unknown" if you dont know - that's fine. If you know, this helps us make sure you get a discount.

What is the highest deductible you can handle without financial difficulty?*

Do you own anything else with a motor or wheels, other than lawnmower, like an ATV, Side-by-side, Motorcycle, Golf Cart, Scooter, RV, Camper, Trailer, Jet Ski, Boat, etc?*

What do you own?*

If one of your vehicles were not driveable for a month, would it be a problem or could you go about your normal daily activities?*

If you or your family are badly injured in a car accident, how important is it to have compensation (money) available from your policy?*

Half of all cars have LESS than $30,000 of insurance or assets to compensate you for damage they do to you (pain, lost wages, loss of limb or sight, etc)

Would you like to add accident forgiveness to keep your rate from increasing after a claim?*

Half of all cars have LESS than $30,000 of insurance or assets to compensate you for damage they do to you (pain, lost wages, loss of limb or sight, etc)

It is important to get OEM parts if your vehicles is damaged or be paid 10% above the repair value? *

Half of all cars have LESS than $30,000 of insurance or assets to compensate you for damage they do to you (pain, lost wages, loss of limb or sight, etc)

If things go well this year, what is your annual household income?*

Best guess is fine - this helps us give guidance on which levels of liability protection and uninsured motorist we should have you consider (we may suggest considering more or less, since we don't want to assume what you set up previously is still best today)

What is your approximate net worth? (everything you own, subtract everything you owe)*

Best guess is fine - this helps us give guidance on which levels of liability protection and uninsured motorist we should have you consider (we may suggest considering more or less, since we don't want to assume what you set up previously is still best today)

Remember, no coverages can be bound, changed, or cancelled until you get confirmation from a licensed agent of the McGinniss Himmel Insurance Agency, LLC. This form allows us to more accuratly and quickly help get you taken care of but submission of this form does not confirm or change your coverage. We OFTEN can respond to these within 2-4 hours, but please allow us 24 hours to review and contact you with options and confirmation of coverage.

In connection with your quote and/or 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. (please see below for more details)

I understand and have read the full disclosure below*

Please verify that you are human*

Please read this notice carefully. This notice contains important information you should know.
Insurance companies may use insurance scoring, in part, to determine the rate you are charged for insurance. A credit report will be ordered on you and the resulting Insurance Score may be used as an additional criteria for rating purposes.
Information about you and your credit experiences, such as payment history, the number and type of accounts with late payments, collection actions, outstanding debt, and the age of your accounts is collected from your credit report. Using a
statistical program, specialized companies compare this information to the credit performance of consumers with similar profiles. An insurance scoring system assigns points for each factor and a final score is determined.
It is in your best interest to check your credit history in order to determine the accuracy. If there is adverse information in your credit record, credit reporting companies are required to provide you with this information. A copy of your credit
report can be obtained by contacting LexisNexis Consumer Service Center at 1-888-497-0011 or online at www.consumerdisclosure.com.
Insurance companies cannot use credit history or an Insurance Score for any arbitrary, capricious or unfairly discriminatory reason. Additionally, credit history or an Insurance Score based wholly or partly on residence, sex, race, color, creed, occupation, income, physical handicap or disability of an applicant or insured is prohibited.
The Florida Department of Financial Services offers free financial literacy programs to assist you with insurance-related questions, including how credit works and how credit scores are calculated. To learn more, visit www.MyFloridaCFO.com.