Your Personal Insurance Questionnaire Step 1 of 6 0% Basic InformationFirst Named Insured(Required) First Last 1st Named - EducationHigh SchoolAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOther1st Named - Employment Second Named Insured First Last 2nd Named - EducationHigh SchoolAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOther2nd Named - Employment Primary Contact Person(Required)First Named InsuredSecond Named InsuredSomeone ElseContact Person if not named insured First Last Primary Contact Phone(Required)Primary Contact Email(Required) Primary Contact Address(Required) Street Address Address Line 2 City 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 State ZIP Code BackgroundHow did they hear about GRIT Insurance?Who do you have your insurance with now?How long have they had your business?BudgetWhat is your current budget for your personal Insurance?What is your timeline for having us complete the market analysis for and present you with your options?Would you be interested in insurance recommendations to add protection you didn't have now if added only 10-20% to your current insurance budget? Yes No Do you have a business insurance you'd like us to talk about at another time? Yes No Types of Personal Insurance PoliciesI am interested in... Auto Home Secondary Home Rental Property Recreational Vehicle (Boat, Motorcycle, ATV, etc) Umbrella Other Select AllOther Policy Type Auto Insurance InformationCurrent Auto Carrier Current Agency/Carrier How Long Auto Expiration Date MM slash DD slash YYYY Current Auto BI LimitState Minimum$50,000 / $100,000$100,000 / $300,000$250,000 / $500,000$300,000 CSL (Combined Single Limit)$500,000 CSL (Combined Single Limit)Current Auto Property Damage Limit$10,000$50,000$100,000$250,000$500,000Household Drivers (+/- to add/remove)First NameLast NameDate of BirthDriver License #Good Student DiscountLast Citation(s) Add RemoveGood Student = Ages 16–25 with a GPA of 3.0 or higher. Household Vehicles (+/- to add/remove)YearMakeModelVINDriverUse : Pleasure, Commute or Business Add Remove Homeowners InformationCurrent address less than 3 years Yes No Own, Rent or BuyingOwnRentBuyingPrior Address Street Address Address Line 2 City State ZIP Policy TypeHomeownerRentersCondoTownhouseLandlord ProtectorMobile HomeUnits in BuildingHome TypeSingle Story1.5 Story2 StorySplit LevelBi-Level/Raised RanchTownhome (end)Townhome (mid)OtherCurrent Home Carrier Current Carrier How Long Current Home CoveragesDwellingSeparate StructuresPersonal PropertyLiabilityDeductibleWind Hail Deductible Add RemoveHome InformationYear BuiltSq FtRoof ReplaceFurnace ReplaceUpdates? Add RemoveSQ FT above groundBasement? Yes No Basement SQ FTBasement % FinishedGarage TypeAttached 1 CarAttached 2 CarAttached 3 CarBult-in 1 CarBult-in 2 CarBult-in 3 CarCarportDetached# of Bathrooms12345678910# of Fireplaces12345678910Roof TypeAsphalt/ShingleWood ShakeConcrete/CementOtherExterior Walls % of EachBrick VeneerAluminum/Vinyl SidingStucco on FrameStone VeneerWood SidingOther Add RemoveType of Electrical Type of Plumbing Type of HVAC Alarm System Yes No Sewer & Drain Coverage Yes No Buried Utilities Yes No Additional Features Add Value to the Property Deck Hot Tub Pool Central Vac Patio Cover Other Are you interested in getting the following additional coverages for your home? Earthquake Coverage Flood Coverage Interested in additional liability insurance coverage? (Umbrella) $1,000,000 $2000,000 $3,000,000 $4,000,000 $5,000,000 Other home Information you would like us to know Any additional comments or questions you may have for us
