Personal Lines Quote Form "*" indicates required fields Step 1 of 41 2% Name* First Last Email Address* Mobile Phone*Is it ok if we text you?* Yes, texting makes things quick & easy! No, I don't like texting. What is your current home address?* Street Address 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 Have you moved within the past five years?* Yes No What was your previous address?* Street Address 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 What kind of insurance proposal can we prepare for you today?* Auto Home Renters Landlord Dwelling Mobile/Manufactured Home Motorcycle/ATV Motorhome/Camper Boat/Watercraft Personal Umbrella Life Insurance Pet Insurance Tornado Crisis Insurance Other Select all that applyHow did you hear about us?* I'm a current Blue Marsh client Google / Online Search Social Media I was contacted by Blue Marsh Referred by someone Other GREAT....we LOVE referrals! Who referred you to us?*Can you provide some details for us?* What is your date of birth?* MM slash DD slash YYYY And your relationship status?* Single Married Domestic Partner Spouse's InformationName* First Last Date of Birth* MM slash DD slash YYYY Email Address* Mobile Phone*Permission to text?* Yes No Domestic Partner's InformationName* First Last Date of Birth* MM slash DD slash YYYY Email Address* Mobile Phone*Permission to text?* Yes No Driver InformationYour Driver's License Number:*Your Driver's License State:*Please SelectAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificSpouse's Driver's License Number:*Spouse's Driver's License State:*Please SelectAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDomestic Partner's Driver's License Number:*Domestic Partner's Driver's License State:*Please SelectAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAre there additional drivers in your household?* Yes No Additional Household Drivers:*Driver NameRelationship (Child, Parent, etc.)Date of BirthDriver's License NumberDriver's License State Add RemoveDo any household drivers qualify for a Good Student Discount?* Yes No Please upload current grade transcripts:*Max. file size: 39 MB. Auto InsuranceWhen would you like your new auto insurance policy to start?* MM slash DD slash YYYY Do you currently have auto insurance?* Yes No What is the name of your current auto insurance company?*If possible, please upload a copy of your current auto insurance policy here:Max. file size: 39 MB. Auto InsuranceLiability CoverageBodily Injury Liabilty*Please Select$50,000/$100,000$100,000/$300,000$250,000/$500,000$500,000/$500,000Property Damage Liability*Please Select$50,000$100,000$250,000$500,000Uninsured Motorist - Bodily Injury*Please Select$50,000/$100,000$100,000/$300,000$250,000/$500,000$500,000/$500,000Medical Payments*Please SelectNo Coverage$1,000$5,000$10,000$25,000$50,000$100,000 Auto InsuranceHow many household vehicles need to be listed on this policy?*Please Select12345678More than 8Vehicle 1Year*Please Select202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955Prior to 1955Make*Model*VINComprehensive*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleCollision*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleRoadside Assistance*Please SelectYesNoRental Reimbursement*Please SelectYesNoVehicle 2Year*Please Select20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955Prior to 1955Make*Model*VINComprehensive*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleCollision*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleRental Reimbursement*Please SelectYesNoRoadside Assistance*Please SelectYesNoVehicle 3Year*Please Select20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955Prior to 1955Make*Model*VINComprehensive*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleCollision*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleRental Reimbursement*Please SelectYesNoRoadside Assistance*Please SelectYesNoVehicle 4Year*Please Select20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955Prior to 1955Make*Model*VINComprehensive*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleCollision*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleRental Reimbursement*Please SelectYesNoRoadside Assistance*Please SelectYesNoVehicle 5Year*Please Select20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955Prior to 1955Make*Model*VINComprehensive*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleCollision*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleRental Reimbursement*Please SelectYesNoRoadside Assistance*Please SelectYesNoVehicle 6Year*Please Select20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955Prior to 1955Make*Model*VINComprehensive*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleCollision*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleRental Reimbursement*Please SelectYesNoRoadside Assistance*Please SelectYesNoVehicle 7Year*Please Select20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955Prior to 1955Make*Model*VINComprehensive*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleCollision*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleRental Reimbursement*Please SelectYesNoRoadside Assistance*Please SelectYesNoVehicle 8Year*Please Select20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955Prior to 1955Make*Model*VINComprehensive*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleCollision*Please SelectNo Coverage$250 Deductible$500 Deductible$1,000 Deductible$1,500 Deductible$2,500 Deductible$5,000 DeductibleRental Reimbursement*Please SelectYesNoRoadside Assistance*Please SelectYesNo Auto InsuranceTelematicsSome of our auto insurance carriers offer a Telematics program. These programs allow the insurance company to use smartphone technology or a device that plugs directly into your vehicle to monitor certain driving habits in order to qualify you for discounts as high as 30%.If available, would you like to enroll in telematics?* Yes No Please feel free to provide any additional information you think we may need in order to provide the most accurate auto insurance proposal for you. Motorcycle / ATVWhen would you like this new insurance policy to start?* MM slash DD slash YYYY How many years of experience do you have operating motorcycles or ATV's?*If you have a current motorcycle or ATV policy, please upload a copy here.Max. file size: 39 MB. Motorcycle / ATVList all Motorcycles/ATV's below:*YearMakeModelVIN (if available)Collision DeductibleComprehensive Deductible Add RemovePlease feel free to provide any additional information you think we may need in order to provide the most accurate auto insurance proposal for you. Motorhome / CamperWhen would you like this new insurance policy to start?* MM slash DD slash YYYY List all Motorhomes/Campers below:*YearMakeModelVIN (if available)Collision DeductibleComprehensive Deductible Add RemoveStorage location when not in use:*Please SelectResidential - inside storageResidential - outside storagePublic - inside storagePublic - outside storagePlease feel free to provide any additional information you think we may need in order to provide the most accurate Motorhome/Camper insurance proposal for you. Boat / WatercraftWhen would you like this new insurance policy to start?* MM slash DD slash YYYY How many years of experience do you have operating watercraft?*If you have a current Boat/Watercraft policy, please upload a copy here.Max. file size: 39 MB. Boat / WatercraftList all Boats/Watercrafts below:*YearMakeModelVIN (if available)Collision DeductibleComprehensive Deductible Add RemovePlease feel free to provide any additional information you think we may need in order to provide the most accurate Boat/Watercraft insurance proposal for you. Homeowners InsuranceWhen would you like your new homeowner insurance policy to start?* MM slash DD slash YYYY Is this for a new home purchase?* Yes No Is there a mortgagee / lienholder?* Yes No Will this policy be paid via mortgage escrow?* Yes No Mortgagee / Lienholder Name:*Is the property address the same as your previously entered home address?* Yes No Please enter the property address:* Street Address 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 If you have a current homeowners insurance policy on this house, please upload a copy here.Max. file size: 39 MB. Homeowners InsuranceHow will this home be used?* Primary Residence Secondary Residence Seasonal Residence What year was the home built?*Please Select202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924prior to 1924Please select the foundation type:*Please SelectCrawlspaceSlabBasementOtherSpecify "Other" foundation type:*% of basement that is finished:*Please enter a number from 0 to 100. Homeowners InsuranceHome Square Footage (living space):*Number of Stories (not incl. basement):*Please enter a number from 1 to 4.Please select all types of floorcoverings that are present in the home:* Hardwood Ceramic Tile Carpet Laminate Vinyl Stone Main Exterior Wall Material:*Please SelectBrickVinyl SidingStoneCement Fiber SidingMetal SidingWood SidingStuccoLogOtherPlease Specify Exterior Wall Material:*When was the roof last updated?*Please Select202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924prior to 1924What type of roof is on the house?*Please SelectArchitectural ShinglesAsphalt ShinglesWood ShinglesMetalOtherPlease Specify the Roof Type:* Homeowners InsuranceWhat is the primary heat source?*Please SelectElectric Heat PumpGas HeatFireplaceWood Burning StoveFurnaceHow many bathrooms are in the house?*Please enter a number from 1 to 20.Are there any dogs on the premises?* Yes No Please list all dogs below:*BreedAny history of biting? (Yes/No) Add RemoveIs there a swimming pool on the premises?* Yes No Is the pool fenced with a locking gate?* Yes No Is there a diving board or slide?* Yes No Is there a trampoline on the premises?* Yes No Is the trampoline fenced?* Yes No Homeowners InsuranceDesired amount of dwelling coverage:*You can skip this if you aren't sure.Desired Policy Deductible:*Please Select$1,000$1,500$2,000$2,500$5,000$7,500$10,000OtherThe deductible is the amount you will pay if you have a claim.Please specify your desired deductible:*Please select all security devices that are present: Deadbolt Locks Fire Extinguisher Local Smoke/Fire Alarm Local Burglar Alarm Monitored Fire Alarm Monitored Burglar Alarm Automatic Water Sensors Please feel free to provide any additional information you think we may need in order to provide the most accurate homeowner insurance proposal for you. Renters InsuranceWhen would you like your new renters insurance policy to start?* MM slash DD slash YYYY Type of Rental Dwelling:*Please SelectSingle Family ResidenceApartment UnitDuplex UnitTriplex UnitQuadplex UnitName of the Apartment Complex:*Is the address the same as your previously entered home address?* Yes No What is the correct property address?* Street Address 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 If you have a current renters insurance policy, please upload a copy here.Max. file size: 39 MB. Renters InsuranceDesired amount of Personal Property Coverage:*Please Select$25,000$50,000$75,000$100,000OtherPlease specify your desired amount of Personal Property Coverage:*This is coverage for all of your personal belongings (clothing, furniture, electronics, dishes, etc.)Desired amount of Personal Liability Coverage:*Please Select$100,000$300,000$500,000$1,000,000Please check with your landlord or property manager. Your rental agreement may include a required minimum amount of personal liability coverage.Please feel free to provide any additional information you think we may need in order to provide the most accurate renters insurance proposal for you. Landlord DwellingWhen would you like your new Landlord Dwelling insurance policy to start?* MM slash DD slash YYYY Is there a mortgagee / lienholder?* Yes No Will this policy be paid via mortgage escrow?* Yes No Mortgagee / Lienholder Name:*Please enter the property address:* Street Address 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 If you have a current landlord dwelling insurance policy on this house, please upload a copy here.Max. file size: 39 MB. Landlord DwellingWhat year was the home built?*Please Select202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924prior to 1924Please select the foundation type:*Please SelectCrawlspaceSlabBasementOtherSpecify "Other" foundation type:*% of basement that is finished:*Please enter a number from 0 to 100. Landlord DwellingHome Square Footage (living space):*Number of Stories (not incl. basement):*Please enter a number from 1 to 4.Main Exterior Wall Material:*Please SelectBrickVinyl SidingStoneCement Fiber SidingMetal SidingWood SidingStuccoLogOtherPlease Specify Exterior Wall Material:*When was the roof last updated?*Please Select202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924prior to 1924What type of roof is on the house?*Please SelectArchitectural ShinglesAsphalt ShinglesWood ShinglesMetalOtherPlease Specify the Roof Type:* Landlord DwellingWhat is the primary heat source?*Please SelectElectric Heat PumpGas HeatFireplaceWood Burning StoveFurnaceHow many bathrooms are in the house?*Please enter a number from 1 to 20.Is there a swimming pool on the premises?* Yes No Is the pool fenced with a locking gate?* Yes No Is there a diving board or slide?* Yes No Is there a trampoline on the premises?* Yes No Is the trampoline fenced?* Yes No Landlord DwellingDesired amount of dwelling coverage:*You can skip this if you aren't sure.Desired Policy Deductible:*Please Select$1,000$1,500$2,000$2,500$5,000$7,500$10,000OtherThe deductible is the amount you will pay if you have a claim.Please specify your desired deductible:*Please select all security devices that are present: Deadbolt Locks Fire Extinguisher Local Smoke/Fire Alarm Local Burglar Alarm Monitored Fire Alarm Monitored Burglar Alarm Automatic Water Sensors Please feel free to provide any additional information you think we may need in order to provide the most accurate homeowner insurance proposal for you. Mobile / Manufactured HomeWhen would you like this new policy to start?* MM slash DD slash YYYY Is this for a new home purchase?* Yes No Is there a mortgagee / lienholder?* Yes No Will this policy be paid via mortgage escrow?* Yes No Mortgagee / Lienholder Name:*Is the property address the same as your previously entered home address?* Yes No Please enter the property address:* Street Address 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 If you have a current insurance policy on this home, please upload a copy here.Max. file size: 39 MB. Mobile / Manufactured HomeHow will this home be used?* Primary Residence Secondary Residence Seasonal Residence Is it located in an approved park?* Yes No What is the name of the park?* Mobile / Manufactured HomeMake (if known)Model Year*Please Select202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924prior to 1924Width (ft.)*Length (ft.)*Is the home tied down?* Yes No Is there skirting around the foundation?* Yes No Main Exterior Wall Material:*Please SelectBrickVinyl SidingStoneCement Fiber SidingMetal SidingWood SidingStuccoLogOtherPlease Specify Exterior Wall Material:*When was the roof last updated?*Please Select202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924prior to 1924What type of roof is on the house?*Please SelectArchitectural ShinglesAsphalt ShinglesWood ShinglesMetalOtherPlease Specify the Roof Type:* Mobile / Manufactured HomeWhat is the primary heat source?*Electric Heat PumpGas HeatFireplaceWood Burning StoveFurnaceHow many bathrooms are in the house?*Please enter a number from 1 to 20.Is there a swimming pool on the premises?* Yes No Is the pool fenced with a locking gate?* Yes No Is there a diving board or slide?* Yes No Is there a trampoline on the premises?* Yes No Is the trampoline fenced?* Yes No Mobile / Manufactured HomeDesired amount of dwelling coverage:*You can skip this if you aren't sure.Desired Policy Deductible:*Please Select$1,000$1,500$2,000$2,500$5,000$7,500$10,000OtherThe deductible is the amount you will pay if you have a claim.Please specify your desired deductible:*Please select all security devices that are present: Deadbolt Locks Fire Extinguisher Local Smoke/Fire Alarm Local Burglar Alarm Monitored Fire Alarm Monitored Burglar Alarm Automatic Water Sensors Please feel free to provide any additional information you think we may need in order to provide the most accurate homeowner insurance proposal for you. Personal Liability UmbrellaWhen would you like this new policy to start?* MM slash DD slash YYYY Desired amount of liability coverage*Please Select$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000$6,000,000$7,000,000$8,000,000$9,000,000$10,000,000If you have a current Personal Liability Umbrella policy, please upload a copy here.Max. file size: 39 MB. Personal Liability UmbrellaNumber of Household Vehicles*Number of Owner-Occupied Homes*Number of Rental Units Owned*Number of Boats/Watercrafts*Number of Household Members Under the age of 25*Number of Household Off-Road Vehicles*Number of Household Motorcycles Personal Liability UmbrellaIs there a business operated on the residence premises?* Yes No Description of Business*Is any farming conducted on the residence premises?* Yes No Description of farming operations on residence premises*Does any member of the household hold an elected office or a high-profile position?* Yes No Please describe the elected office or high-profile position*Please feel free to provide any additional information you think we may need in order to provide the most accurate Personal Liability Umbrella proposal for you. Life InsuranceHow much life insurance coverage do you need?*What type of life insurance do you want?* Term Life Whole Life Universal Life Burial Policy How long would you like your Term Life policy to last?* 10 Years 15 years 20 Years 25 Years 30 Years Life InsuranceSex:* Male Female Weight (lbs.)*Height (in inches)*ex. 5'10" = 70" Life InsuranceDo you use any kind of nicotine or tobacco products?* Yes No Please describe your nicotine/tobacco usage:*Have you ever had a life insurance application declined?* Yes No Please provide details regarding your previous life insurance declination:* Life InsurancePlease select all medical conditions that apply:* Cancer Heart Disease / Heart Attack Asthma Sleep Apnea Stroke COPD / Emphysema Crohn's Disease Lupus Other Please provide details regarding your Cancer:*Please provide details regarding your Heart Disease / Heart Attack:*Please provide details regarding your Asthma:*Please provide details regarding your Sleep Apnea:*Please provide details regarding your Stroke:*Please provide details regarding your COPD / Emphysema:*Please provide details regarding your Crohn's Disease:*Please provide details regarding your Lupus:*Please provide details regarding your other medical conditions:* Life InsuranceDo you take any prescription medications?* Yes No Please list all prescription medications you are currently taking*MedicationDosageFrequencyCondition Treated Add RemoveAre both of your biological parents still living?* Yes No Did either of them die prior to age 60 due to a heart-related condition?* Yes No Please provide any additional information you think we may need in order to provide the most accurate Life Insurance proposal for you. Tell us what you're looking for...Please provide some details below and we'll see what we can find for you!* One last question...How would like to receive your proposal?* Email Phone Call Text Message Postal Mail Please verify your mailing address:* Street Address 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 All done!Once you're finished, go ahead and click "Submit" and we'll get to work for you as quickly as possible.Please use the box below if there's any additional information you need to share with us.Consent* I agree to the Blue Marsh Insurance Privacy Policy.The full terms and conditions of our Privacy Policy can be found at: https://www.bluemarsh.com/privacy/
