Pre-Appointment Form Step 1 of 16 6% An Introduction Kim and Jeff Hastings are proud Cypress, Texas residents and business owners who love to help others in the community. Active volunteers and parents of six, they understand the needs of the clients they are privileged to serve. Bringing old-fashioned values and service to an industry that may have seemed to have drifted into a cold and uncaring world, their clients value the honesty, sincerity and professional advice the agency is known for. As a retired librarian in the Cy-Fair school district, Kim utilizes her teaching experience to help educate clients on the complex world of insurance. Jeff has worked in the insurance industry for over 30-years and recently retired from his position as a district manager for Farmers Insurance where he hired and trained professional agents in the Houston area. The two together make a powerful team who can provide the expertise, support and education you deserve when making your insurance buying decision! Although we have great rates, we don't want you to select our agency on rates alone! We are selective in the clients we choose and look for those who value the advice and relationship of a professional insurance agency. If you live in or around the coastal area, you realize how important it is to have an agent you trust and an insurer who is large enough to pay your claims. Let's face it, not all insurers are alike and neither are the agencies who represent them. While rates change on a frequent basis, the top insurers charge about the same rate over a 10-year continuum. So, instead of choosing an agency based on rate, consider choosing a professional agency you trust who will take the time to explain your coverage options, verify there are no duplicate coverage's and make certain you are getting every discount you are qualified to receive! We are a proud small business owners and representative of the Farmers Insurance Group of Companies which is one of the largest and most respected insurers in the nation. Representing over 10-million households across all 50-states, you can rest assured that Farmers will stand behind their promise to get you back where you belong! In addition to Farmers, we represent these fine companies! Save and Continue Later Your InformationWant to save time? If we are simply quoting an existing policy that is in force, feel free to jump to our online DOCUMENT Portal and upload a complete copy of your insurance declarations page! Click on this link for more details: Upload Current PolicyName First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Our agency is licensed in the State of Texas. To find an agent in another state, please visit www.Farmers.com. Save and Continue Later Maximize Your Discounts! Have us quote all of your insurance needs. From the boxes below and to the right, select all you would like us to look at either now or in the future. Auto/Home Auto - Personal Auto - Collectible Home - Private Residence Home - Secondary Home - Rental (You Own) Renters (Home or Apartment) Condo Mobile Home Motor Home Umbrella - Increase Liability BUSINESS Business Property Business Liability Business - Life (Partnership) Business - Life (Key Person) Business - Life (Buy/Sell) Workers Compensation Business Auto Umbrella - Professional Health Insurance - For Business Miscelleneous Life Insurance Health Insurance Flood Insurance Boat Insurance Investments or Annuities College Funding Motorcycle Off-Road Vehicle Golf Cart Travel Trailer 5th Wheel Collections or Jewelry Floater Pet Insurance Not including yourself, how many additional people live at this address?*0123451. Your Legal Name: First Last 1. Relationship*SELF1. Your Date of Birth Date Format: MM slash DD slash YYYY 2. Additional Household Member Name: First Last 2. Relationship*Spouse or Domestic PartnerChildMotherFatherBrother or SisterOther RelativeFriend2. Date of Birth Date Format: MM slash DD slash YYYY 3. Additional Household Member Name: First Last 3. Relationship*Spouse or Domestic PartnerChildMotherFatherBrother or SisterOther RelativeFriend3. Date of Birth Date Format: MM slash DD slash YYYY 4. Additional Household Member Name: First Last 4. Relationship*Spouse or Domestic PartnerChildMotherFatherBrother or SisterOther RelativeFriend4. Date of Birth Date Format: MM slash DD slash YYYY 5. Additional Household Member Name: First Last 5. Relationship*Spouse or Domestic PartnerChildMotherFatherBrother or SisterOther RelativeFriend5. Date of Birth Date Format: MM slash DD slash YYYY 6. Additional Household Member Name: First Last 6. Relationship*Spouse or Domestic PartnerChildMotherFatherBrother or SisterOther RelativeFriend6. Date of Birth Date Format: MM slash DD slash YYYY IMPORTANT: Make certain to select the type of policy we are helping you with before proceeding to the next page. Save and Continue Later Life InsuranceHow Many Policies Would You Like Quoted?12345678910 or MoreHow Long will You Need Coverage?*10-years of Less10-20 Years20-Year or LongerReason for Coverage Family Protection Business Protection Estate Planning Insurability Loan or Collateral Employee Benefit Would you like a policy that can accumulate cash value?*YesNoNot CertainDo you have children who rely on your financially?*YesNoWould you like to include calculations for college planning?YesNoWould you like help selecting the right amount of coverage?NoYesSelecting Coverage AmountYears Left Working:Enter the number of years you plan on working at your income level or higher.Years Until Death:Using average life expectancy, how many years do you expect to be living? (Average = 78 yrs) https://www.ssa.gov/OACT/population/longevity.htmlA. MONTHLY INCOME:PolicyholderPolicyholder Monthly Income (after Taxes):SpouseSpouse Monthly Income (after taxes):Child Support or Alimony Received:Monthly Child Support Received:Rental IncomeMonthly Rental Income:OtherList additional monthly income here:TOTAL MONTHLY INCOME:B. MONTHLY EXPENSES:House PaymentHouse payment including insurance and taxes:Health Insurance:Child Support or Alimony Paid:Dining and Entertainment:Phone and Internet:Auto 1 Payment:Auto 2 Payment:Auto 3 Payment:Groceries:Monthly Credit Card Payments:Other Monthly Household Expenses:TOTAL EXPENSES:Long-Term LiabilitiesTotal Owed on Home:Total Owed on Autos:Total Owed on Credit Cards:C. TOTAL LONG-TERM LIABILITIES:Current Insurance in Forcea. Head of Household Name:a. Temporary (TERM) Insurance:a. Permanent Insurance Face Amount:b. Head of Household Name:b. Temporary (TERM) Insurance:b. Permanent Insurance Face Amount:D. (a) TOTAL INSURANCE IN-FORCE:(b) TOTAL INSURANCE IN-FORCE:Cash, Savings and RetirementCurrent Short Term Cash (90-days liquid):Retirement Savings:Other Long-Term Investments:TOTAL CASH, SAVINGS & RETIREMENT: Save and Continue Later College Expense PlanningWill your children attend a public or private university?*PublicPrivate Here are some COAs that colleges reported for the 2015-2016 academic year. These costs are for undergraduates living on campus and enrolled in liberal arts programs. Public colleges (for state residents): University of Arizona (Tucson) – $25,740 University of California (Berkeley) – $35,365 University of Idaho (Moscow) – $20,294 University of North Carolina (Chapel Hill) – $24,349 University of Massachusetts (Amherst) – $28,784 University of Michigan (Ann Arbor) – $27,812 Examples of Private and Public COAs Here are some COAs that colleges reported for the 2015-2016 academic year. These costs are for undergraduates living on campus and enrolled in liberal arts programs. Private colleges: Cornell University (Ithaca, NY) – $65,494 Duke University (Durham, NC) – $67,339 Grinnell College (Grinnell, IA) – $61,098 Rice University (Houston, TX) – $58,283 Stanford University (Palo Alto, CA) – $65,177 Swarthmore College (Swarthmore, PA) – $63,980Child 1Child 2Child 3Public Yearly College Tuition, Room and BoardPublic Yearly College Tuition, Room and BoardPublic Yearly College Tuition, Room and BoardPrivate Yearly College Tuition, Room and BoardPrivate Yearly College Tuition, Room and BoardPrivate Yearly College Tuition, Room and BoardNumber of Years in School:Number of Years in School:Number of Years in School:Amount Saved:Amount Saved:Amount Saved:a. Balance Needed to Pay for Public College Expense:b. Balance Needed to Pay for Public College Expense:c. Balance Needed to Pay for Public College Expense:a. Balance Needed to Pay for Private College Expense:b. Balance Needed to Pay for Private College Expense:c. Balance Needed to Pay for Private College Expense: Save and Continue Later Family ProtectionYour Desire for Partner/Family:Minimum Protection5-Year Adjustment FundI don't want my family to worry about money.Protect InsurabilityYour Desire for Partner/Family:Minimum Protection5-Year Adjustment FundI don't want my family to worry about money.Business PartnershipPrimary purpose for life insurance in partnership:Business ContinuationCompensation to Surviving Partner FamilyOtherEstate PlanningYour Desire for Partner/Family:Minimum Protection5-Year Adjustment FundI don't want my family to worry about money.Business LoanLoan Amount: Save and Continue Later 1. Policy DetailLife Policy 1 Name First Last Date of BirthAmount of Coverage Desired:Type of Policy DesiredUnknownPermanent - Whole LifeTemporary 10 YearsTemporary 20 YearsPermanent - Variable Universal LifePermanent - Universal LifeTemporary 30 YearsBeneficiary Information:Condition of Health:Have you ever received a DUI or DWI? If so, when did it occur?NoYes - 1 timeYes - 2 or more2. Policy DetailLife Policy 2 Name First Last Date of BirthAmount of Coverage Desired:Type of Policy DesiredUnknownPermanent - Whole LifeTemporary 10 YearsTemporary 20 YearsPermanent - Variable Universal LifePermanent - Universal LifeTemporary 30 YearsBeneficiary Information:Condition of Health:Have you ever received a DUI or DWI? If so, when did it occur?NoYes - 1 timeYes - 2 or more3. Policy DetailLife Policy 3 Name First Last Date of BirthAmount of Coverage Desired:Type of Policy DesiredUnknownPermanent - Whole LifeTemporary 10 YearsTemporary 20 YearsPermanent - Variable Universal LifePermanent - Universal LifeTemporary 30 YearsBeneficiary Information:Condition of Health:Have you ever received a DUI or DWI? If so, when did it occur?NoYes - 1 timeYes - 2 or more4. Policy DetailLife Policy 4 Name First Last Date of BirthAmount of Coverage Desired:Type of Policy DesiredUnknownPermanent - Whole LifeTemporary 10 YearsTemporary 20 YearsPermanent - Variable Universal LifePermanent - Universal LifeTemporary 30 YearsBeneficiary Information:Condition of Health:Have you ever received a DUI or DWI? If so, when did it occur?NoYes - 1 timeYes - 2 or more5. Policy DetailLife Policy 5 Name First Last Date of BirthAmount of Coverage Desired:Type of Policy DesiredUnknownPermanent - Whole LifeTemporary 10 YearsTemporary 20 YearsPermanent - Variable Universal LifePermanent - Universal LifeTemporary 30 YearsBeneficiary Information:Condition of Health:Have you ever received a DUI or DWI? If so, when did it occur?NoYes - 1 timeYes - 2 or moreCurrent Medications:Current Medications:Type of Policy DesiredUnknownPermanent - Whole LifeTemporary 10 YearsTemporary 20 YearsPermanent - Variable Universal LifePermanent - Universal LifeTemporary 30 YearsBeneficiary Information:Condition of Health:Have you ever received a DUI or DWI? If so, when did it occur?NoYes - 1 timeYes - 2 or more Save and Continue Later Health Insurance Save and Continue Later Auto InsuranceWould you like more information on selecting the appropriate liability limits?YesNoWhat liability limits would you like quoted?Texas law requires people who drive in Texas to pay for the accidents they cause. Most drivers do this by buying auto liability insurance. Liability insurance pays to repair or replace the other driver's car and pays other people's medical expenses when you are at fault in an accident. If you buy insurance to meet the state's financial responsibility law, you must buy at least the minimum amount. The current minimum liability limits are $30,000 for each injured person, up to a total of $60,000 per accident, and $25,000 for property damage per accident. This basic coverage is called 30/60/25 coverage. Because of car prices and the high cost of medical care, the minimum amounts might not be enough to pay all of the other driver's costs if you're in an accident. Other drivers could sue you to collect the difference. Consider buying more than the basic limits to protect yourself financially. Liability insurance doesn't pay to repair or replace your car or to treat your injuries. Consider buying other types of coverage - such as medical payments, collision, and comprehensive - to pay for these expenses.30/60 (state minimum)50/100100/300250/500500/500UnknownSelecting the Right CoverageDo you drive children not related to you in your vehicle?YesNoDo you use vehicle car for business?YesNoSelect the type of business use your vehicle is used for:Realtor or Real Estate ProfessionalIncidental Mail or Bank DepositsContractor ServicesMy company requires me to use my personal vehicle for business.OtherIf you transport tools to/from sites, you may not be able to obtain a personal auto policy. Request a business auto policy and provide details about your tools to insure proper coverage.As a Realtor, you will need to carry 250/500 liability and purchase a $1 million umbrella policy.What type of business use is your vehicle used for? If more than one vehicle is covered, please identify which vehicle is used for this purpose.If you are at fault in an auto accident, your primary residence (with homestead exemption), annuities, corporate assets and retirement assets are considered protected assets. Non-protected assets could include personal checking/savings accounts, CD's, stocks, and other non-retirement investment accounts and secondary residences. What is the estimated value of your Unprotected Assets?0 - $99,999$100,000 - $249,999$250,000 - $499,999$500,000 - $749,999$750,000 - $999,999$1m - $1.99m$2 million or moreBecause of your assets and/or your increased exposure, we HIGHLY recommend you consult with a professional licensed insurance agent before proceeding. Be sure to ask about how an annuity can protect your estate in large loss settlements.Carrying a lower amount of liability (50/100) coverage may be adequate in your situation; however, we do recommend you sit down with a professional insurance agent.You may want to consider at least 100/300 as your minimum liability coverage for your autos. However, we highly suggest you meet with a professional insurance agent.To protect your assets, you may want to consider at least 250/500 as your minimum liability coverage; however, we highly suggest you meet with a professional insurance agent.To protect your assets, you may want to consider at least 250/500 and a $1 million personal umbrella. However, we HIGHLY recommend you consult with a professional insurance agent.To fully protect your assets, we highly encourage you to speak with a professional insurance agent before choosing your auto liability coverage.Because of your financial situation, we highly recommend you meet personally with a professional insurance agent to determine the proper liability coverage for your personal auto.Would you like Personal Injury Protection (PIP) or Med-Pay (Med)?Medical payments coverage, or “Med-Pay” as it is sometimes referred to, is another form of health insurance coverage for medical expenses incurred due to a motor vehicle accident. Med-Pay is offered as an alternative to PIP. You can purchase one or the other, but not both. Just like Personal Injury Protection (PIP), this coverage is available to the insured driver and any passengers in the insured’s vehicle for medical expenses due to injuries sustained in the wreck, regardless of the fault of the driver. Again, the insurance policy of a negligent third party will not pay Med-Pay or PIP benefits. There are several differences between PIP and Med-Pay coverage: 1.) PIP covers 80% of documented lost wages and earnings – Med-Pay has no coverage for lost wages and only covers medical bills; 2.) PIP does not have to be repaid to your insurer, even if you recover from a third party – If you recover from a third party, Med Pay must be paid back to your insurer; 3.) PIP will even cover medical expenses incurred due to an accident on a motorcycle, moped, scooter or motorized bicycle designed for use on public roads – Med-Pay excludes coverage for medical expenses incurred due to injuries while on a motorized vehicle having fewer than 4 wheels. If you have any questions about your auto insurance coverage, we would be happy to discuss to make certain you select the coverage that's best for you.No CoveragePIPMedA deductible is the amount of money you would be comfortable paying out of pocket to repair your car for a covered loss.Comprehensive Coverage Option (Other than Collision)When people hear the word "comprehensive," they might think "all-encompassing"— but in car insurance terms, the word has a different meaning. Comprehensive coverage may help protect your car against damages that are not related to a collision, such as: Theft Vandalism Fire Natural disasters (like a hurricane or a tornado) Falling objects Damage done to your car by animals A civil disturbance (like a riot that results in damage or destruction of your car) As with all insurance policies, you should check with your insurance agent to make sure what perils are included under the comprehensive coverage of your auto insurance policy. Because a deductible represents the amount you will pay for a covered loss, the higher deductible you select, the lower your insurance premiums will be.No Coverage$250$500$1,000Collision Coverage OptionCollision coverage covers damage to your car in a variety of situations. If you hit another car‐the damage to your car would be covered by this part of your policy. For example, if you hydroplane on a wet road and hit a tree, damaging your front bumper, Collision coverage would take care of the repair costs—less your deductible. Collision is an optional coverage and to include it on your policy, you must also purchase Comprehensive coverage. If you lease or finance your car, your bank may require Collision coverage. Because the deductible is the amount you would paid for a covered loss, the higher the deductible you select, the lower your insurance premium will be.No Coverage$250$500$1,000DISCLAIMERThe material provided on The Insurance Teacher.com website and our social media sites, including the information and any images incorporated in the site, is for your personal private non-commercial use only. You may not modify, republish, post or transmit anything you obtain from this website, including anything you download from the site, unless you first obtain our consent. You agree not to engage in systematic retrieval of data or other content from theinsuranceteacher.com. We request that you not create any kind of hyperlink from any other site to ours unless you first obtain our permission. It is very important that you read the next two sections carefully. LIMITATION OF LIABILITY THE KIM HASTINGS AGENCY, INC. (www.theinsuranceteacher.com), WILL NOT BE RESPONSIBLE FOR ANY DAMAGES OR INJURIES THAT ACCOMPANY OR RESULT FROM YOUR USE OF ITS SITES. THESE INCLUDE (BUT ARE NOT LIMITED TO) DAMAGES OR INJURY CAUSED BY ANY: (1) USE OF (OR INABILITY TO USE) THE SITES; (2) USE OF (OR INABILITY TO USE) ANY SITE TO WHICH YOU HYPERLINK FROM ITS WEBSITES; (3) FAILURE OF PERFORMANCE; (4) ERROR; (5) OMISSION; (6) INTERRUPTION; (7) DEFECT; (8) DELAY IN OPERATION OR TRANSMISSION; (9) COMPUTER VIRUS; OR (10) LINE FAILURE. WE ARE NOT LIABLE FOR ANY CONSEQUENTIAL OR INCIDENTAL DAMAGES, WHICH ARE DAMAGES INTENDED TO COMPENSATE SOMEONE DIRECTLY FOR A LOSS OR INJURY, DAMAGES REASONABLY EXPECTED TO RESULT FROM A LOSS OR INJURY, OR OTHER MISCELLANEOUS DAMAGES AND EXPENSES RESULTING DIRECTLY FROM A LOSS OR INJURY. FURTHERMORE, EXCEPT AS PROVIDED BELOW, WE ARE NOT LIABLE EVEN IF WE HAVE BEEN NEGLIGENT OR IF OUR AUTHORIZED REPRESENTATIVE HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES—OR BOTH. HOWEVER, IN CERTAIN STATES WHERE THE LAW MAY NOT ALLOW US TO LIMIT OR EXCLUDE LIABILITY FOR THESE INCIDENTAL OR CONSEQUENTIAL DAMAGES, THE ABOVE LIMITATION MAY NOT APPLY AND YOU MAY HAVE THE RIGHT TO RECOVER THESE TYPES OF DAMAGES. IN ANY EVENT, OUR LIABILITY TO YOU FOR ALL LOSSES, DAMAGES, INJURIES AND CLAIMS OF ANY KIND, WHETHER THE DAMAGES ARE CLAIMED UNDER THE TERMS OF A CONTRACT, OR THEY ARE CLAIMED TO BE CAUSED BY NEGLIGENCE OR OTHER WRONGFUL CONDUCT OR ANY OTHER LEGAL THEORY, WILL NOT BE GREATER THAN THE AMOUNT YOU HAVE PAID TO ACCESS OUR SITES. DISCLAIMER THE MATERIAL ON OUR SITES IS PROVIDED AS IS. THIS MEANS THAT THE KIM HASTINGS AGENCY, INC. DISCLAIMS ALL EXPRESS AND IMPLIED WARRANTIES ABOUT THE MATERIAL IN THE SITES. THIS INCLUDES, BUT IT IS NOT LIMITED TO, WARRANTIES THAT: (1) THE MATERIAL IS OF ANY PARTICULAR LEVEL OF QUALITY OR IS FIT FOR A PARTICULAR PURPOSE; (2) THAT THE FUNCTIONAL ELEMENTS CONTAINED IN THE MATERIALS WILL BE UNINTERRUPTED OR ERROR-FREE; (3) THAT DEFECTS WILL BE CORRECTED; (4) THAT OUR SITES, OR THE SERVERS THAT MAKE THEM AVAILABLE ARE FREE OF COMPUTER VIRUSES OR OTHER HARMFUL COMPONENTS OR CONDITIONS; OR (4) THAT INFORMATION CONTAINED IN THE SITES IS ACCURATE AS OF ANY PARTICULAR DATE. Digital Assistant TheInsuranceTeacher.com Digital Assistant is intended for informational purposes only. Any information provided is not intended as insurance advice and should not be interpreted as such. Any insurance decision, including coverage amounts, limits, and deductibles, is solely and ultimately the responsibility of the insured. The Kim Hastings Agency, Inc. is not liable for any information that is inaccurate, missing, or misinterpreted. The material contained within the Digital Assistant is subject to change at any time, and the Kim Hastings Agency, Inc. makes no guarantee about the quality or accuracy of said content. JURISDICTION Unless otherwise specified, the materials in our site are presented to provide information about the coverage options provided by the Kim Hastings Agency, our insurance products and the insurance business. The Kim Hastings Agency operates and controls its sites from the Company’s headquarters in Cypress, Texas, in the United States of America, and Texas and law shall govern and control any action concerning The Insurance Teacher websites. We do not in any way imply that the materials on the sites or the products we discuss are available or for use outside the United States or in jurisdictions in which we are not licensed to do business, or that we are soliciting business in any such jurisdiction. By completing an on-line request for a rate quote, you are confirming that you are not a resident in any such jurisdiction. By using theinsuranceteacher.com website, you agree to these Terms and Conditions of Website Use. MISCELLANEOUS These Terms and Conditions of Website Use, and the agreement they create, shall be governed by and interpreted according to the laws of the State of Texas, without giving effect to Texas’ conflict of laws principles. If any provision of this agreement is unlawful, void or unenforceable, it shall not affect the validity and enforceability of any remaining provisions. The Kim Hastings Agency, Inc. may modify these Terms and Conditions of Website Use, and the agreement they create, at any time, simply by updating this posting or the information on its website and without notice to you. By selecting "NEXT" below, you are Agreeing to the Terms and Conditions mentioned above.Vehicle InformationVehicle #1VINYearMakeModelVehicle #2VINYearMakeModelVehicle #2VINYearMakeModelVehicle #3VINYearMakeModelVehicle #4VINYearMakeModelVehicle #5VINYearMakeModelIf your car is 10-years or older, before selecting Comp and/or Collision coverage, contact us to find out why adding this coverage it may not be in your best interest.Driver InformationDriver #1 - Primary Named InsuredTDL #Driver #2TDL #Driver #3TDL #Driver #4TDL #Driver #5TDL #Additional Driver or information we may need to know:Current Insurance Company:How long have you had continuous coverage (may earn discount):Desired Effective Date* Date Format: Save and Continue Later Home InsuranceHome TypeSingle FamilyMulti-FamilyModularYear BuiltNumber of StoriesOneOne and a HalfTwoTwo and a HalfThreeType of RoofComp ShingleWoodCopperRolledTin or MetalOther or UnkFoundationSlabPeer and BeemSquare Footage of HouseGarageAttachedDetached (breezeway)Detached (no breezeway)No GarageGarage TypeNo GarageSingle CarTwo CarThree CarFour CarNumber of Fireplaces012345Number of Baths11.522.533.544.555.566.577.588.599.510 or morePool?YesNoJacuzzi or Hot Tub?YesNoOutdoor KitchenYesNoOther Property that May Need to be Scheduled: Guns Coins Jewelry Art Collectibles Other Current Insurance Company:Estimated Replacement Cost Value:Current County Tax Appraised Value:Loan Amount:Is this policy needed for a closing?YesNoRealtor Name (if for a closing):Lender Information:Mortgagee Clause:This policy may qualify for a bundle discount! Would you like us to quote your auto insurance as well?YesNoMaybe LaterYour homeowners policy does not provide flood insurance. Would you like us to prepare a quote at the same time?YesNoMaybe LaterPremium and Coverage AmountFlood InsuranceWhat kind of home do you live in?Single Family HomeSingle Family CondoTwo to Four Family BuildingOther Residential with More than 4 UnitsIs your home over water?Not Over WaterPartially Over WaterOver WaterIs this your primary residence?Yes, 80% or More of the TimeYes, 51% - 79% of the YearNo, reside 50% or Less of the YearDo you use this building for business use?No, 100% Personal UseYes as a Home Based BusinessYes, this is a business only property.Do you own this property?YesNo, I'm renting.Do you rent this building to someone else?NoYesAre you aware of any flood insurance claims that have been reported on this home?NoYesPlease give details about the prior flood claim including the date the loss occurred.Please select your desired flood coverage limits:Building and ContentsContents OnlyReplacement Cost InformationI have read and agree to the Replacement Cost Information:* Yes No I have read and agree to the Replacement Cost Information:* Yes No Renters InsuranceProperty Type:HomeApartmentDuplexCondoMobile HomeOtherName of Apartment Complex or Neighborhood:Month and Year you moved into this address:Estimated Value of Personal Property:This policy may qualify for a package discount. Check all that may apply: Auto with Farmers Life with Farmers This policy may qualify for a package discount. Check all that may apply: Auto with Farmers Life with Farmers Are you currently covered?YesNoCurrent Coverage Provider:Is your currently policy under COBRA benefits?YesNoNot CertainPlanned Effective Date of New Policy:GenderFemaleMaleHow many people are in your household (or away at college)?12345678910Are you self-employed?YesNoGive additional details if needed:Give additional details if needed: Save and Continue Later MotorcycleYear of Motorcycle:Make and Model of Motorcycle:Do you currently have motorcycle insurance?YesNoWhen was your motorcycle purchased? Date Format: Do you have your auto insurance with our agency or plan to?*Yes - I am a current client of this agency.Yes - I am requesting to move my auto insurance to your agency.NoMotorcycle UseDrive to/from School or HomePleasure Use OnlyEffective Date of Coverage Request: Date Format: Pet InsuranceEffective Date of Coverage Request: Date Format: Type of PetDogCatBird or ExoticPet's NameAge of Your PetAge of Your PetBoat InsurancePurchase Date Date Format: Year of Boat:MakeModelLength of BoatWhere is boat stored or docked (or will be)?Use of Boat:PleasureRacing or Speed ContestBusiness or Commercial UseWill you make the boat available to others for a fee?YesNoWill your boat be your primary residence?YesNoMarket Value of Boat:Leinholder InformationLeinholder Information Save and Continue Later Condo InsuranceDate Purchased Date Format: Year BuiltMakeModelLength or SizeOption 1Option 2Option 3Current Estimated ValueCurrent Estimated ValueDate Purchased Date Format: Current Estimated ValueYear BuiltMakeModelLength or SizeOption 1Option 2Option 3Length or SizeOption 1Option 2Option 3Year BuiltWho will occupy the condo unit?*SelfRenterIs the condo in a gated community?YesNoNumber of Floors in Building1234 or moreAddress (if different)Address 2CityZip / Post CodeEstimated Value of ContentsProperty Manager or Leasing Agent Contact Information (name, phone and email):Property Manager or Leasing Agent Contact Information (name, phone and email): Save and Continue Later Mobile Home InsuranceYear of Mobile HomeMake and/or ModelLengthWidthWhere is the mobile home located?Private PropertyMobile Home CommunityOtherUse of Mobile HomePrimary ResidenceRent to OthersSecondary ResidenceHunting LeaseOtherIs the home permanently installed (wheels removed)?YesNoIs the home skirted?YesNoNot CertainIs the home skirted?YesNoNot Certain Save and Continue Later AnnuityWhere are funds coming from?Bank Checking or Savings AccountAnother AnnuityRetirement DistributionOtherWill this annuity be set up as a qualified retirement program?YesNoNot CertainAdditional Information:Additional Information: Save and Continue Later Business InsuranceCompany NameDate Coverage DesiredPrimary Business Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of BusinessOwners Years in BusinessIs this business currently insured?YesNoAmount of Liability Coverage DesiredAmount of Liability Coverage DesiredDate Coverage Requested to be In ForceInput Claims History Below or Upload FileWorkers Compensation InsuranceDo you have current Workers Compensation Insurance?YesNoCurrent Insurance ProviderState of DomicileAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingIs workers compensation required in employers state of domicile?NoYesUnknownNumber of EmployeesTotal Annual Payroll:Does employer offer paid health insurance plan?YesNoDoes employer offer paid health insurance plan?YesNoDate Coverage Desired: Date Format: Business Auto InsuranceIs your personal auto insurance covered by our agency now?YesNoWill Be Issued at Same TimeDate Coverage Desired Save and Continue Later Prior InsuranceUpload Prior Insurance Here:There is no need to scratch out the amount you pay...we really do not have the ability to manipulate rates. And if we did, we would ALWAYS do our best to reduce your premium.Type of Prior Insurance CarrierI have an Insurance AgentMy Current Company Does Not Have Insurance Agents (Direct)N/AIs the total amount you pay for insurance (auto/home/life/health/business) a significant part of your monthly budget?YesNoWhen was the last time you have had an agent has sit down to review your insurance program?Less than 1-year1-3 Years3-5 Years5-10 YearsOver 10-YearsNeverDo you believe having a professional agent who cares enough to take the time to review your coverage to make sure you are properly covered and have every discount your are entitled to is valuable?YesMaybeNo, I just want a quote.If you don't mind us asking, from the list below, what is the reason for your interest to switch insurance companies? My rates are too high. My agent does not return calls promptly. Lack of a trained support staff. Poor claims experience. No personalized service. I would like an agent to review my policy. Other Is there anything else we could do to earn your business? If so, please indicate below. Your suggestions are sincerely appreciated.Who may we thank for referring you to us?Who may we thank for referring you to us?To help us make certain we are apply every discount you may be entitled to receive, please check which discounts you believe you may qualify for.Planning Ahead Bundle Discounts Early Shopper - Check if the effective date of this policy be at least 7 or more days away from today. Pay in Full - Check if you plan to pay your entire premium in one lump sum. Transfer from Pref Carrier - Check if you have insurance in force now with a preferred carrier. Auto Pay (EFT) - Check if you will be paying with auto bank draft. Professional Affinity Groups Accountant Educators Engineer Firefighter Military Law Enforcement Vehicle Discounts Multi-Car Alternative Fuel Student Discounts Student 100-Miles Away Good Student Teen Driver Home Discounts New Home Home Renovation New Roof UL Approved Roof Non-Smoker Home Safety Protective Devices Home Discounts New Home Home Renovation New Roof UL Approved Roof Non-Smoker Home Safety Protective Devices Please make certain that you have completed all of the required information before submitting. If you have any questions, please contact us at 281-379-5400. If it is after hours, you are welcome to email firstname.lastname@example.org.DisclaimerHave you read and agree to this disclaimer?NoYesHave you read and agree to this disclaimer?NoYes Save and Continue Later How did Kim do?