Insurance Proposal - Chapman Insurance Group

Please select the category that your insurance needs fall under:(Required)

Home - Auto - Recreational Vehicle

Flood

Life

Hidden

Home - Auto - Rec. Vehicle

Hidden

Flood

Do you own the home?(Required)

Yes, this is insurance for my home

No, this is for insurance for my rental

Is the home being rented to others?(Required)

Yes, more than 9 months of the year

Yes, 6-9 months of the year

Yes, less than 6 months of the year

No, it is not being rented

What type of residence is the home?(Required)

Primary

Seasonal

Investment/Other

Do you have an elevation certificate?(Required)

Yes

No

Unsure

What are you desired flood limits? Note: If you're unsure, please put "unknown."(Required)

Coverages may vary depending on the zone you live in. Typically, the max coverage for building is $250,000 and the max for contents is $100,000.

What is your address?(Required)

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

How long have you lived at the home?(Required)

More than 3 years

Less than 3 years

Please provide your previous address

Address(Required)

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

How many years did you live here?(Required)

Ok, great! Before we continue, please let us know how we can contact you regarding your quote:

Name(Required)

First Last

Email(Required)

Phone(Required)

What is your preferred method of contact?(Required)

Email

Text

Call

Thank you! We’ll just need a little more information.

What is your sex?(Required)

What is your marital status?(Required)

What is your date of birth?(Required)

What is your highest level of education?(Required)

What is your occupation?(Required)

Would you like to add a co-applicant to this policy? *Note: Co-applicants are listed on the primary policy and can take actions on the account.(Required)

No, thanks

Yes, please

Hidden

Flood: Co- Applicant Section

Great! Please tell us a little about them.

Name(Required)

First Last

What is their sex?(Required)

What is their marital status?(Required)

What is their date of birth?(Required)

What is their highest level of education?(Required)

What is their occupation?(Required)

What is their relation to you?(Required)

Hidden

Life

Before we continue, please let us know how we can contact you regarding your quote:

Name(Required)

First Last

Email(Required)

Phone(Required)

What is your preferred method of contact?(Required)

Email

Text

Call

Thank you! We’ll just need a little more information.

What is your sex?(Required)

What is your marital status?(Required)

What is your date of birth?(Required)

What is your height?(Required)

What is your weight?(Required)

Do you use or have you ever used tobacco products?(Required)

Yes, currently

Yes, in the past

No, I've never used tobacco products

Do you drink or have you ever drank alcohol?(Required)

Yes, currently

Yes, in the past

No, I've never drank alcohol

Do you or your family have a history of any major medical diseases/disorders?(Required)

Yes

No

Unsure

Please provide the disease/disorder & the relation of the person to you:(Required)

For example: lung cancer - brother.

What is your highest level of education?(Required)

What is your occupation?(Required)

What is your desired death benefit amount? If unsure, please put "unknown."(Required)

Thank you for the opportunity to serve you! Please enter your information in the form and I will be in touch shortly.

-Ben Miller, Personal Lines Sales (Licensed Agent)

Let's get started!

Home - Auto - Rec. Vehicle

Flood

Flood: Co- Applicant Section

Life