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Would You Like Us To Review Your Policies?

Full Legal Name*
First Last Suffix
Address for Requested Quote*
Street Address Address Line 2 City State ZIP Code
Current Address*
Street Address Address Line 2 City State ZIP Code
Prior Address (If less than 5 years at current address)
Street Address Address Line 2 City State ZIP Code
Phone*
May we text you about your quote?*
We'll never text for solicitation purposes, only about your quote or policy information. It's a great way to obtain quick information if we have a quick question.
Email*
Insurance Score Approval*
Please note in order to get an accurate quote, the majority of insurance companies run an insurance score which includes a soft credit inquiry. By completing this form you are authorizing Bay Area Insurance Shop and it's companies to complete any requested.
- I agree
What would you like a quote for?*
- Auto Only
- Home Only
- Renters Only
- Auto and/or Home/Renters
- Umbrella & Excess Liability
- Investment / Rental Property
- Flood Insurance
- Watercraft
- Motorcycle /ATV
Document Upload
This is not required, but if readily available, please upload your most current insurance policy coverage declarations pages in PDF format so we can see the exact coverage limits you'd like us to compare. These can be easily downloaded from your online profile with your current provider (if you have a login) or from your current agent.
Max. file size: 39 MB.
Driver Information
Please list personal information for all drivers in your household if you need auto insurance.
How Many Drivers?*
Please choose the number of drivers who need to be listed for your insurance. All licensed drivers in your household should be listed.
Primary Residence*
- Own Home/Condo
- Own Manufactured Home
- Rent
Do any household drivers:*
- Use their vehicle for business purposes
- Drive for Uber/Lyft or any RideShare
- Deliver Packages for Amazon/Shipt/Other Delivery Services
- Deliver Meals/Food (ie: GrubHub, Uber Eats, DoorDash/Pizza)
- Participate in Turo
- Nobody has business use, drives rideshare, delivers food or packages or participates in Turo
Name - Driver 1
First Last
Sex*
- Male
- Female
Occupation*
Highest Level of Education Completed*
Date of Birth - Driver 1*
Month
Day
Year
Drivers License Number & State Driver 1*
Does this driver have claims/accidents or tickets in the last 5 years?
Name - Driver 2
First Last
Sex*
- Male
- Female
Occupation*
Highest Level of Education Completed*
Date of Birth - Driver 2
Month
Day
Year
Drivers License Number & State Driver 2
Does this driver have claims/accidents or tickets in the last 5 years?
Name - Driver 3
First Last
Sex*
- Male
- Female
Occupation*
Date of Birth - Driver 3
Month
Day
Year
Drivers License Number & State Driver 3
Does this driver have claims/accidents or tickets in the last 5 years?
Name - Driver 4
First Last
Sex*
- Male
- Female
Occupation*
Date of Birth - Driver 4
Month
Day
Year
Drivers License Number & State Driver 4
Does this driver have claims/accidents or tickets in the last 5 years?
Name - Driver 5
First Last
Sex*
- Male
- Female
Occupation
Date of Birth - Driver 5
Month
Day
Year
Drivers License Number & State Driver 5
Does this driver have claims/accidents or tickets in the last 5 years?
Vehicle Information
How Many Vehicles Need to be Insured?
Vehicle ID (VIN) Number-Vehicle 1*
Lienholder (Bank) Name*
Vehicle Use*
How Much Coverage Should Be Quoted? (Vehicle #1)
- Liability Only
- Liability, Comprehensive & Collision
Vehicle Identification (VIN) Number-Vehicle 2*
Lienholder Name*
Vehicle Use*
How Much Coverage Should Be Quoted? (Vehicle #2)
- Liability Only
- Liability, Comprehensive & Collision
Vehicle Identification (VIN) Number-Vehicle 3
Lienholder (Bank) Name*
Vehicle Use*
How Much Coverage Should Be Quoted? (Vehicle #3)
- Physical Damage
- Liability Only
Vehicle Identification (VIN) Number-Vehicle 4
Lienholder Name*
Vehicle Use*
How Much Coverage Should Be Quoted? (Vehicle #4)
- Physical Damage- Including Comprehensive & Collision Coverage
- Liability Only
Which of the Following Coverage's Should Be Included?
- Towing
- Rental Car
- Towing and Rental Car
- None of the Above
Please provide a summary of claims, accidents or tickets for each household driver*
Please include dates of incident and amount of claim if known.
Current Policy Liability Limits*
Who Is Your Current Insurance Company & How Many Years Have You Been With Them?*
Please provide current premium
Preferred Payment Option
Home Owner Information
How many people are on the deed or the rental agreement?
The home will be deeded to:
Please provide name of Trust or LLC
Legal Name of First Deeded Owner/Renter
First Last
Sex*
- Male
- Female
Date of Birth*
Month
Day
Year
Legal Name of Second Deeded Owner
First Last
Relationship
Sex*
- Male
- Female
Date of Birth*
Month
Day
Year
Has any deeded owner had a foreclosure, bankruptcy, lien or judgement in the past 5 years?*
- Yes, Owner 1
- Yes, Owner 2
- Yes, Both Deeded Owners
- Nobody has this
Property Information
Is this a new purchase?*
Effective Date of Policy*
Closing date if new purchase or renewal date of current policy
Is there/will there be a mortgage on the home?
Contact Info for Mortage Company
Please provide name, phone & fax for a contact for the mortgage company.
Current Homeowners Insurance Carrier*
If this is not a new purchase, what company currently insures your property?
This home will be used as a*
- Primary Residence
- Seasonal/Secondary Residence
- Non-Owner Occupied/Rental Property
Please describe the home style
- Single Family Home
- Townhouse (Association is a Condo Association)
- Townhouse (Association is a Homeowners Association)
- Condo
- Mobile/Manufactured Home
- Home/Apartment (Renters Insurance)
Please provide Manufacturer & Dimensions
Value of the home
Provide the insurance amount you're considering purchasing or the cost to replace this home.
Mobile Home Land Information
- Located on Private Property
- 55+ Mobile Home Park (Land Owned By Me)
- 55+ Mobile Home Park (Do not own land)
- Located in family park
Name of Mobile Home Park
Please provide information for additions or upgrades
Provide sizes of screen enclosures, carports, etc
Year Built
Square Footage
Exterior Finish of Home
Year of Last Roof Update*
Please provide Wind Mitigation Inspection if current in the last five years.
Homes 15 and older: Water Heater Year
Please Provide a Current Four Point Inspection If Home Is Over 40 years old.*
- Not Over 40 Years Old
- Will Upload Inspection
- Request a referral for home inspector to do this
Alarm System Present?
- Interested in a referral for alarm service
- Yes, Installed and Monitored through Central Station Monitoring Service (please upload monitoring certificate for discount)
- Yes, Installed but not monitored
- No
Is There a Swimming Pool Present?
- Yes
- No
Is your home community gated or does it have a single entry point?*
If you have pets, please advise what breed of any dogs.*
Please let us know if any of these apply*
Please let us know if any of these apply to any property you may own or rent.
- Any breed or mix of the following dog breeds: Akita, American Bulldog, American Staffordshire Terrier, Belgian Malinos, Bull Terrier, Cane Corso, Caucasian Mountain Dog, Chow, Doberman Pinscher, Dutch Shepherd, German Shepherd, Mastiff, Olde English Bulldog, Pit Bull, Presa Canario, Rottweiler, Staffordshire Terrier, Wolf/Wolf Hybrid?
- Any dogs that have been trained for guard or attack purposes
- Any dog used in military or police work
- Unfenced or Unscreened Pool
- Diving Board, Pool Slide or Trampoline
- Mini-Bikes, ATV, Dirt Bike
- Farm Animals
- I do not have any of the above liability exposures.
Have you experienced any claims on any property in the past 5 years?*
Please provide date, property address and details if yes in the Coverage Details box below.
- Yes
- No
Claim Details
Please provide a description of the claim including date of loss, amount of claim and if the repair work has been completed & the claim has been closed.
Is there any additional information that would assist us with your quotes?
Who referred you to Bay Area Insurance Shop?*
The majority of our business comes from referrals! Who can we thank for referring you to our agency?

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Would You Like Us To Review Your Policies?

Driver Information

Vehicle Information

Home Owner Information

Property Information

Request Your Proposal Here