Quote Form

Shane Vander Giessen

Name of Person Submitting the Form:*
First Last
Email of Person Submitting the Form:*
Phone of Person Submitting the Form:*
Quote Type*
Who referred you?

Home Quote Form
Property Type*
- Home
- Condo
- Secondary
Property Address*
Street Address City State ZIP Code
Year Built*
Square Feet of Your Home?*
How much are you currently paying?
Has your Roof Been Updated?*
- Yes
- No
If so, when?*
Month
Day
Year
Custom or Designer Materials In:
- Kitchen
- Bathrooms
Previous Address
If you have owned this property less than 1 year, what is your prior address?

Street Address City State ZIP Code
Date of Birth*
Month
Day
Year
Occupation*
If applicable, Spouse/Partner DOB
Month
Day
Year
Any claims filed in the last 5 years?*
- Yes
- No
Describe nature and date of claim*
Any special High Value items you're concerned about?*
- Yes
- No
Item description and value:*
Sprinkler system inside the home?*
- Yes
- No
If so, is the system:*
- Full
- Partial
Is the property in a gated community?*
- Yes
- No
If gated, is it guard gated?*
- Yes
- No
Burglar and Fire System Connection*
Are they connected to a monitoring company?
- Yes
- No
If yes, who is the monitoring vendor?*
Do you have any of the following?*
- Pool
- Jacuzzi
- Water Slide
- Diving Board
- Solar Panels
- None
How Many Solar Panels?*
Do you have any of the following?*
- Live-In Nanny
- Regular Service People
- Tree House
- Skate Board Ramps
- Homes Based Business
- Wood or Pellet Stove
- Farming Operations
- None
Do you have a trampoline?*
- Yes
- No
If so, does it have a safety net?*
- Yes
- No
Do you have dogs?*
- Yes
- No
If so, what breeds?*
Do you have any of the following polices?*
- Earthquake
- Flood
- Umbrella
- None
Auto Quote Form
Driver Count*
How many drivers are insured on your policy?
Home Address*
Street Address City State ZIP Code
Driver #1
Name*
First Last
Driver's License #*
Driver's License State*
Date of Birth*
Month
Day
Year
Sex*
- Male
- Female
Driver #2
Name*
First Last
Driver's License #*
Driver's License State*
Date of Birth*
Month
Day
Year
Sex*
- Male
- Female
Driver #3
Name*
First Last
Driver's License #*
Driver's License State*
Date of Birth*
Month
Day
Year
Sex*
- Male
- Female
Driver #4
Name*
First Last
Driver's License #*
Driver's License State*
Date of Birth*
Month
Day
Year
Sex*
- Male
- Female
Driver #5
Name*
First Last
Driver's License #*
Driver's License State*
Date of Birth*
Month
Day
Year
Sex*
- Male
- Female
Driver #6
Name*
First Last
Driver's License #*
Driver's License State*
Date of Birth*
Month
Day
Year
Sex*
- Male
- Female
Requested Coverage Info
Liability Limits*
- 25/50/25
- 50/100/50
- 100/300/100
- 250/500/100
Uninsured/Underinsured Motorist Coverage*
- Yes
- No
Medical Payments/PIP*
- Yes
- No
Auto Identification
Insured Vehicles*
How many insured vehicles to you have on your auto insurance policy?
Vehicle #1
Year*
Make*
Model*
VIN #
Approximate Purchase Date*
Month
Day
Year
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Coverage*
- Liability Only
- Comprehensive/No Collision
- Full Coverage
Towing?*
- Yes
- No
Rental Reimbursement?*
- Yes
- No
Gap Coverage?*
- Yes
- No
Vehicle #2
Year*
Make*
Model*
VIN #
Approximate Purchase Date*
Month
Day
Year
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Coverage*
- Liability Only
- Comprehensive/No Collision
- Full Coverage
Towing?*
- Yes
- No
Rental Reimbursement?*
- Yes
- No
Gap Coverage?*
- Yes
- No
Vehicle #3
Year*
Make*
Model*
VIN #
Approximate Purchase Date*
Month
Day
Year
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Coverage*
- Liability Only
- Comprehensive/No Collision
- Full Coverage
Towing?*
- Yes
- No
Rental Reimbusement?*
- Yes
- No
Gap Coverage?*
- Yes
- No
Vehicle #4
Year*
Make*
Model*
VIN #
Approximate Purchase Date*
Month
Day
Year
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Coverage*
- Liability Only
- Comprehensive/No Collision
- Full Coverage
Towing?*
- Yes
- No
Rental Reimbursement?*
- Yes
- No
Gap Coverage?*
- Yes
- No
Vehicle #5
Year*
Make*
Model*
VIN #
Approximate Purchase Date*
Month
Day
Year
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Coverage*
- Liability Only
- Comprehensive/No Collision
- Full Coverage
Towing?*
- Yes
- No
Rental Reimbursement?*
- Yes
- No
Gap Coverage?*
- Yes
- No
Vehicle #6
Year*
Make*
Model*
VIN #
Approximate Purchase Date*
Month
Day
Year
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Coverage*
- Liability Only
- Comprehensive/No Collision
- Full Coverage
Towing?*
- Yes
- No
Rental Reimbursement?*
- Yes
- No
Gap Coverage?*
- Yes
- No
General Vehicle Questions
Aftermarket Options*
Do you have additional aftermarket equipment?
- Yes
- No
If so, which auto, type of equipment, and value?*
Years With Provider*
How many years have you been with your current auto insurance company?
Do you have an auto provided by your employer?*
- Yes
- No
Do you have a AAA membership?*
- Yes
- No
How much are you currently paying?
Discount Questions
Student Drivers*
Do any drivers on your policy under the age of 25 attend school full time and carry a 3.0 or above GPA?
- Yes
- No
If so, list eligible driver names:*
Attendance Proof*
If so, can you provide a copy of the report card as proof of this discount?
- Yes
- No
Rental Property Form
Property Address*
Street Address City State ZIP Code
Is the mailing address the same as the property address?*
- Yes
- No
How much are you currently paying?
Mailing Address*
Street Address City State ZIP Code
Owned Less Than 5 Years
If you have owned less than 5, what is your prior address?

Street Address City State ZIP Code
Your Date of Birth*
Month
Day
Year
Relationship Status*
Your spouse/partner Date of Birth*
Month
Day
Year
Is there a tenant?*
- Yes
- No
If yes, are they full time or part time?*
Is the property used as a seasonal rental, such as AirBNB, Home Away?*
- Yes
- No
Is the property in a Trust, LLC, Corp or Partnership?*
- Yes
- No
Any Claims filed in last 5 years?*
- Yes
- No
If yes, describe and list approximate date:*
Do you have a Sprinkler System inside your home?*
- Yes
- No
If so, is the system:*
- Full
- Partial
Is the property located in a Gated Community?*
- Yes
- No
If gated, is it guard gated?*
- Yes
- No
Do you have any of the following?*
- Pool
- Jacuzzi
- Both
Do you have Earth Quake insurance?*
- Yes
- No
Do you have Flood insurance?*
- Yes
- No
Renter's Form
Property Address*
Street Address City State ZIP Code
Your Date of Birth*
Month
Day
Year
Select your personal property amount of coverage:*
How much are you currently paying?
Do you have any Jewelry that should be insured?*
- Yes
- No
If yes, describe and list its value:*
Do you have dogs?*
- Yes
- No
If so, what breeds?*
Any High Value items you’re concerned about?*
- Yes
- No
What Kind of High Value Items and What is the Value?*
Are you required to provide proof of insurance to your property manager?*
- Yes
- No
Motorcycle/ATV Form
How many Driver's operate your Motorcycle/ATV?*
Home Address*
Street Address City State ZIP Code
Driver #1
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Driver's License State*
Motorcycle Endorsement?*
- Yes
- No
Sex*
- Male
- Female
Driver #2
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Driver's License State*
Motorcycle Endorsement?*
- Yes
- No
Sex*
- Male
- Female
Driver #3
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Driver's License State*
Motorcycle Endorsement?*
- Yes
- No
Sex*
- Male
- Female
Driver #4
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Driver's License State*
Motorcycle Endorsement?*
- Yes
- No
Sex*
- Male
- Female
Driver #5
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Driver's License State*
Motorcycle Endorsement?*
- Yes
- No
Sex*
- Male
- Female
Driver #6
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Driver's License State*
Motorcycle Endorsement?*
- Yes
- No
Sex*
- Male
- Female
Requested Coverage Info
Liability Limits*
- 25/50/25
- 50/100/50
- 100/300/100
- 250/500/100
Underinsured Motorist Coverage?*
- Yes
- No
Medical Payments/PIP*
- Yes
- No
Motorcycle/ATV Identification
How many Motorcycle/ATV's need insured?*
Motorcycle/ATV #1
Year*
Make*
Model*
VIN #
Miles Driven Per Year*
Primary Driver*
First Last
Full Coverage?*
- Yes
- No
Number of CC's*
Motorcycle/ATV #2
Year*
Make*
Model*
VIN #
Miles Driven Per Year*
Primary Driver*
First Last
Full Coverage?*
- Yes
- No
Number of CC's*
Motorcycle/ATV #3
Year*
Make*
Model*
VIN #
Miles Driven Per Year*
Primary Driver*
First Last
Full Coverage?*
- Yes
- No
Number of CC's*
Motorcycle/ATV #4
Year*
Make*
Model*
VIN #
Miles Driven Per Year*
Primary Driver*
First Last
Full Coverage?*
- Yes
- No
Number of CC's*
Motorcycle/ATV #5
Year*
Make*
Model*
VIN #
Miles Driven Per Year*
Primary Driver*
First Last
Full Coverage?*
- Yes
- No
Number of CC's*
Motorcycle/ATV #6
Year*
Make*
Model*
VIN #
Miles Driven Per Year*
Primary Driver*
First Last
Full Coverage?*
- Yes
- No
Number of CC's*
Motorcycle/ATV General Questions
Do you have additional aftermarket equipment?*
- Yes
- No
If so, how much aftermarket equipment?*
Do you have an Umbrella insurance policy?*
- Yes
- No
How much are you currently paying?
Boat Form
Home Address*
Street Address City State ZIP Code
Year*
Make*
Model*
Hull #
Length*
Motor Style
- Inboard
- Outboard
Horse Power*
Cost New*
Current Value*
Years of Operating Experience:*
Where is it stored?*
Street Address City State ZIP Code
Is it stored in a secured or fenced in area?*
- Yes
- No
How much are you currently paying?
Motor Home/Travel Trailer Form
How many Driver's operate your Motor Home?*
Home Address*
Street Address City State ZIP Code
Driver #1
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Driver's License State*
Sex*
- Male
- Female
Driver #2
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Driver's License State*
Sex*
- Male
- Female
Driver #3
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Driver's License State*
Sex*
- Male
- Female
Driver #4
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Driver's License State*
Sex*
- Male
- Female
Driver #5
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Driver's License State*
Sex*
- Male
- Female
Driver #6
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Driver's License State*
Sex*
- Male
- Female
Motor Home/Travel Trailer Identification
Number of Motor Home/Travel Trailer needing insured?*
Motor Home/Travel Trailer #1
Year*
Make*
Model*
VIN #
Miles Driven Per Year*
Length*
Cost New*
Current Value*
Primary Driver*
First Last
Motor Home/Travel Trailer #2
Year*
Make*
Model*
VIN #
Miles Driven Per Year*
Length*
Cost New*
Current Value*
Primary Driver*
First Last
Motor Home/Travel Trailer #3
Year*
Make*
Model*
VIN #
Miles Driven Per Year*
Length*
Cost New*
Current Value*
Primary Driver*
First Last
Motor Home/Travel Trailer #4
Year*
Make*
Model*
VIN #
Miles Driven Per Year*
Length*
Cost New*
Current Value*
Primary Driver*
First Last
Motor Home/Travel Trailer #5
Year*
Make*
Model*
VIN #
Miles Driven Per Year*
Length*
Cost New*
Current Value*
Primary Driver*
First Last
Motor Home/Travel Trailer #6
Year*
Make*
Model*
VIN #
Miles Driven Per Year*
Length*
Cost New*
Current Value*
Primary Driver*
First Last
Motor Home/Travel Trailer General Questions
Do you have additional aftermarket equipment?*
- Yes
- No
If so, how much what kind of aftermarket equipment?*
Where is this stored?*
- Primary Home
- Other
Of "Other" list address:*
Street Address City State ZIP Code
Do you have an Umbrella insurance policy?*
- Yes
- No
How much do you currently pay?
General Document Uploads
Files
In order to make sure we can quote ‘apples-to-apples’ coverage it is extremely helpful if you can upload a copy of your current policy declaration pages (the pages you get at each renewal that shows current coverages/premiums/effective dates/etc.) This is where you can upload those documents.
Drop files here or

Max. file size: 100 MB.
Email
This field is for validation purposes and should be left unchanged.

Quote Form

Shane Vander Giessen

Home Quote Form

Auto Quote Form

Driver #1

Driver #2

Driver #3

Driver #4

Driver #5

Driver #6

Requested Coverage Info

Auto Identification

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

Vehicle #5

Vehicle #6

General Vehicle Questions

Discount Questions

Rental Property Form

Renter's Form

Motorcycle/ATV Form

Driver #1

Driver #2

Driver #3

Driver #4

Driver #5

Driver #6

Requested Coverage Info

Motorcycle/ATV Identification

Motorcycle/ATV #1

Motorcycle/ATV #2

Motorcycle/ATV #3

Motorcycle/ATV #4

Motorcycle/ATV #5

Motorcycle/ATV #6

Motorcycle/ATV General Questions

Boat Form

Motor Home/Travel Trailer Form

Driver #1

Driver #2

Driver #3

Driver #4

Driver #5

Driver #6

Motor Home/Travel Trailer Identification

Motor Home/Travel Trailer #1

Motor Home/Travel Trailer #2

Motor Home/Travel Trailer #3

Motor Home/Travel Trailer #4

Motor Home/Travel Trailer #5

Motor Home/Travel Trailer #6

Motor Home/Travel Trailer General Questions

General Document Uploads