Proposal Request - Personal Lines

Insurance Services of Interest

Business Insurance Services

Check all the business insurance services you are interested in

Commercial Auto Insurance
Commercial Liability Insurance
Commercial Property Insurance
Commercial Umbrella Insurance
Worker’s Comp Insurance
Surety Bonds
Financial Services
Employee Benefits

Personal Insurance Services

Check all the personal insurance services you are interested in

Personal Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Occupation

Business Information

Business Name*

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(If different from address above)

Years in Business

Legal Entity

Business Annual Revenue

# of Owners/Partners

# of Full-Time Employees

# of Part-Time Employees

# of Sub-Contractors

Description of Operations

Annual Payroll

Name of Main Contact*

First Last

Main Contact Phone*

Main Contact Email*

Title of Main Contact

Employee Benefit Solutions

Check all you are interested in.

Group Health Insurance
Group Life Insurance
Group Disability Insurance
401k / Retirement Plans
Supplemental Plans / AFLAC
Key Man Life Insurance
Key Man Disability Insurance
Deferred Compensation

Auto Insurance

How Many Vehicles Do You Wish to Cover?*

Auto Vehicle Information

Year*

Please enter a number from 1900 to 2050.

Make*

Model*

VIN

Vehicle Uses*

Business
Pleasure
School
Work

2nd Vehicle Information

2nd Vehicle Year*

Please enter a number from 1900 to 2050.

2nd Vehicle Make*

2nd Vehicle Model*

2nd Vehicle VIN

2nd Vehicle Uses*

Business
Pleasure
School
Work

3rd Vehicle Information

3rd Vehicle Year*

Please enter a number from 1900 to 2050.

3rd Vehicle Make*

3rd Vehicle Model*

3rd Vehicle VIN

3rd Vehicle Uses*

Business
Pleasure
School
Work

4th Vehicle Information

4th Vehicle Year*

Please enter a number from 1900 to 2050.

4th Vehicle Make*

4th Vehicle Model*

4th Vehicle VIN

4th Vehicle Uses*

Business
Pleasure
School
Work

5th Vehicle Information

5th Vehicle Year*

Please enter a number from 1900 to 2050.

5th Vehicle Make*

5th Vehicle Model*

5th Vehicle VIN

5th Vehicle Uses*

Business
Pleasure
School
Work

Auto Owner Information

Name on Title

First Last

Purchase Date

Ownership

Lease
Loan
Own

Loan/Lease Company

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

2nd Vehicle Owner Information

2nd Vehicle Name on Title

First Last

2nd Vehicle Purchase Date

2nd Vehicle Ownership

Lease
Loan
Own

2nd Vehicle Loan/Lease Company

2nd Vehicle Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

3rd Vehicle Owner Information

3rd Vehicle Name on Title

First Last

3rd Vehicle Purchase Date

3rd Vehicle Ownership

Lease
Loan
Own

3rd Vehicle Loan/Lease Company

3rd Vehicle Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

4th Vehicle Owner Information

4th Vehicle Name on Title

First Last

4th Vehicle Purchase Date

4th Vehicle Ownership

Lease
Loan
Own

4th Vehicle Loan/Lease Company

4th Vehicle Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

5th Vehicle Owner Information

5th Vehicle Name on Title

First Last

5th Vehicle Purchase Date

5th Vehicle Ownership

Lease
Loan
Own

5th Vehicle Loan/Lease Company

5th Vehicle Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Auto Drivers

How Many Drivers Do You Wish to Include?

Auto Driver Information

Driver’s Name*

First Last

Driver’s Date of Birth*

Driver’s Annual Mileage (Estimate)*

Driver Details

Check any that apply.

This is a young driver (under 18 years old)
Has completed driver training
Qualifies for the good-student discount

2nd Driver Information

2nd Driver’s Name*

First Last

2nd Driver’s Date of Birth*

2nd Driver’s Annual Mileage (Estimate)*

2nd Driver Details

Check any that apply.

This is a young driver (under 18 years old)
Has completed driver training
Qualifies for the good-student discount

3rd Driver Information

3rd Driver’s Name*

First Last

3rd Driver’s Date of Birth*

3rd Driver’s Annual Mileage (Estimate)*

3rd Driver Details

Check any that apply.

This is a young driver (under 18 years old)
Has completed driver training
Qualifies for the good-student discount

4th Driver Information

4th Driver’s Name*

First Last

4th Driver’s Date of Birth*

4th Driver’s Annual Mileage (Estimate)*

4th Driver Details

Check any that apply.

This is a young driver (under 18 years old)
Has completed driver training
Qualifies for the good-student discount

5th Driver Information

5th Driver’s Name*

First Last

5th Driver’s Date of Birth*

5th Driver Details

Check any that apply.

This is a young driver (under 18 years old)
Has completed driver training
Qualifies for the good-student discount

5th Driver’s Annual Mileage (Estimate)*

Auto Coverage Information

Auto Coverage Type

Auto Coverage Options

GAP / replacement cost
Medical Payments
Rental Reimbursements
Towing & Rowside Assistance

Boat Information

State Where Boat is Stored

Years of Boating Experience

Boat Type

Boat Length (in Feet)

Boat Maximum Speed (MPH)

Hull

Boat Year

Boat Trade Name

Boat Model

Boat Horsepower

Boat Value ($)

Boat Motor

Boat Motor Year

Boat Motor Trade Name

Boat Motor Horsepower

Boat Motor Value ($)

Boat Trailer

Boat Trailer Year

Boat Trailer Trade Name

Boat Trailer Value ($)

Motorcycle Rider Information

Years of Motorcycle Riding Experience

Consecutive Years Owding a Motocycle

Current Motor Cycle Insurance Company

Motorcycle Information

How Many Motorcycles Do You Wish to Cover?

Motorcycle Year

Motorcycle Make

Motorcycle Model

Motorcycle Engine Size (cc)

Motorcycle parked in garage?

Yes
No

2nd Motorcycle Information

2nd Motorcycle Year

2nd Motorcycle Make

2nd Motorcycle Model

2nd Motorcycle Engine Size (cc)

2nd Motorcycle parked in garage?

Yes
No

3rd Motorcycle Information

3rd Motorcycle Year

3rd Motorcycle Make

3rd Motorcycle Model

3rd Motorcycle Engine Size (cc)

3rd Motorcycle parked in garage?

Yes
No

4th Motorcycle Information

4th Motorcycle Year

4th Motorcycle Make

4th Motorcycle Model

4th Motorcycle Engine Size (cc)

4th Motorcycle parked in garage?

Yes
No

5th Motorcycle Information

5th Motorcycle Year

5th Motorcycle Make

5th Motorcycle Model

5th Motorcycle Engine Size (cc)

5th Motorcycle parked in garage?

Yes
No

Recreational Vehicle Information

RV Type

RV Year

Please enter a number from 1900 to 2550.

RV Make

RV Model

RV Length (feet)

RV Details

RV has one or more anti-theft devices
RV is used for business purposes
RV is your primary residence

Check all that apply

Did you buy your RV new or pre-owned?

New
Pre-Owned

RV Purchase Price ($)

RV Purchase Date

RV Registrant Address (if different from your address)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

RV Additional Information

Years of RV Driving Experience

RV Driver Details

I have taken a defensive driving course
I am a member of an RV association

Current Insurance Company

Current Home Insurance

Do you currently have homeowners insurance?

Yes
No

Current Home Insurance Company

Current Home Insurance Coverage Amount

Current Home Insurance Renewal Date

# of Home Insurance Claims in Last 5 Years

Home Information

Is this home the same as your current address?

Yes
No

Address of Home to Insure

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Year Home Was Built

Home Type

# Stories in Home

Home Construction

Home Foundation

Age of Home Electric (years)

Age of Home Plumbing (years)

Age of Home Heating (years)

Home Interior Features

Home Living Space (sq feet)

# Full Baths in Home

# of Half Baths in Home

# of Chimneys in Home

# of Hearths in Home

Additional Interior Features

Check all that apply

Finished Basement
Central Air Conditioning
Security System

Home Exterior Features

Home Garage Type

Home Garage Size

Home Roof Type

Home Roof Age

Additional Exterior Features

Deck
Screened-in Porch
Outdoor Pool

Check all that apply

Addtional Home Information

Additional Coverage

Check all additional coverage you would be interested in

Jewelry Coverage
Appliance Breakdown
Earthquake
Flood
Identity Theft

Do You Own a Dog?

Yes
No

Renters Insurance Information

This Renter's insurance is for your current address?

Yes
No

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Renter's Coverage Amount

Do You Currently Have Renter's Insurance?

Yes
No

Current Renter's Insurance Company

Renter's Insurance Renewal Date

# of Renter's Insurance Claims in Last 5 Years

Flood Insurance

Is the Flood insurance for you current address?

Yes
No

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Flood Year Built

Home Construction

Home Foundation

Living Space (sq feet)

Do you have a finished basement?

Yes
No

# Flood Losses in Last 5 Years

Dwelling Coverage on Current Homeowner Policy

Umbrella Policy

Requested Coverage

# Drivers Under 25

# Personal Vehicles

Excluding Antique Vehicles

# Business Vehicles

Vehicles your company provides you

# Antique Vehicles

# Boats

# Personal Watecraft

# Motorcycles

# Off-Road Vehicles

# Properties You Occupy

# Rental Units You Own

Rental Property Insurance

I currently have rental property insurance

Yes
No

Rental Property Insurance Company

Current Rental Propery Coverage Amount

Rental Property Insurance Renewal Date

# Rental Property Claims in Last 5 Years

Rental Property Information

Name on Rental Property Title/Deed

First Last

Rental Property Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Year Rental Property was Built

Rental Property Type

Rental Property # of Stories

Rental Property Construction

Rental Property Foundation

Age of Electic in Rental Property (years)

Age of Plumbing in Rental Property (years)

Age of Heating in Rental Property (years)

Rental Property Interior

Rental Property Living Space (sq feet)

# Full Baths in Rental Property

# Half Baths in Rental Property

# Chimneys in Rental Property

Additional Rental Property Interior Features

Check all that apply

Finished Basement
Central Air Conditioning

Rental Property Exerior Features

Rental Property Garage Type

Rental Property Garage Size

Rental Property Roof Type

Rental Property Roof Age

Rental Property Addtional Exterior Features

Check all that apply

Deck
Screened-in Porch
Outdoor Pool

Does Your Rental Propery Tenant Own a Dog?

Yes
No

Comments / Message

Acknowledgement*

I understand no coverage is bound until confirmed in writing by a Teague agent.

Proposal Request – Personal Lines

Request A Proposal

Insurance Services of Interest

Personal Information

Business Information

Auto Insurance

Auto Vehicle Information

2nd Vehicle Information

3rd Vehicle Information

4th Vehicle Information

5th Vehicle Information

Auto Owner Information

2nd Vehicle Owner Information

3rd Vehicle Owner Information

4th Vehicle Owner Information

5th Vehicle Owner Information

Auto Drivers

Auto Driver Information

2nd Driver Information

3rd Driver Information

4th Driver Information

5th Driver Information

Auto Coverage Information

Boat Information

Hull

Boat Motor

Boat Trailer

Motorcycle Rider Information

Motorcycle Information

2nd Motorcycle Information

3rd Motorcycle Information

4th Motorcycle Information

5th Motorcycle Information

Recreational Vehicle Information

RV Additional Information

Current Home Insurance

Home Information

Home Interior Features

Home Exterior Features

Addtional Home Information

Renters Insurance Information

Flood Insurance

Umbrella Policy

Rental Property Insurance

Rental Property Information

Rental Property Interior

Rental Property Exerior Features