Step 1 of 12 8% Primary Insured InformationPrimary Insured Name(Required) First Last Phone(Required)Email(Required) Date of Birth MM slash DD slash YYYY DL StateDL #OccupationIndustryMarital Status(Required)SingleMarriedDivorcedWidowedSpouse InformationSpouse Name First Last Spouse PhoneSpouse Email Spouse Birth Date MM slash DD slash YYYY Spouse Occupation How did you hear about us? Client Referral Mortgage Company Referral Realtor Referral Loan Officer Referral Other Referral Facebook Google Instagram Other What type of insurance can we quote for you?(Required) Auto Home Condo Umbrella Investment Property Motorcycle/Slingshot/ATV Boat RV Other What has you shopping for insurance today?(Required) Current Rates to High Recently Moved New Purchase Unhappy With Previous Provider Other Other:(Required)Referred By Name First Last What other type of insurance can we quote for you?New purchase or already own the condo/home?New PurchaseAlready OwnExpected Closing Date MM slash DD slash YYYY How long have you lived here / Owned the property?How do you use the condo? Primary Residence Secondary Residence Rental Occupancy Status Owner Occupied Tenant Only Occupied Vacant Current Mailing Address (No PO Boxes)(Required) Street Address Address Line 2 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 Is this quote for the same property as your current mailing address?(Required) Yes No Address of Property Being Quoted Street Address Address Line 2 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 Property InformationCurrent InsurerExpiration Date MM slash DD slash YYYY Fireplace(Required) Yes No Diving Board or Slide? Yes No Swimming Pool(Required) Yes No Swimming Pool Enclosed/Fenced? Yes No Monitored Burglar/Fire Alarm? Yes No Dog(s)?(Required) Yes No Dog Breeds Add RemoveIf mixed please indicate type of mix.Any bite history or security training? Yes No Are you aware of any previous settlement or sinkhole issues on the property? Yes No Have you had any home or renter's insurance claims in the past 5 years? Yes No Home Notes (Claim Details)If you selected yes to previous claims please describe here. Home Information ContinuedYear Roof UpdatedRoof Update TypePartialFullYear Electrical UpdatedYear Plumbing Updated?Type of Air ConditioningNoneCentral AirWindow UnitHeating Type?Is there a Basement?YesNoBasement StatusFinishedPartially FinishedUnfinishedFoundation TypeDo you have a Mortgage?YesNoIs it Escrowed?YesNoMortgage Company NameLoan NumberHas home been non-renewed in past 3 years?YesNoAdditional Structures Yes No Additional Structure Description Auto InformationTotal Drivers in Home 1 2 3 4 5 Total Vehicles in Home 1 2 3 4 5 Do you currently have auto insurance?YesNoHave you previously had insurance?YesNoCurrent InsurerPolicy Expiration Date MM slash DD slash YYYY When did your last policy expire? MM slash DD slash YYYY How much do you currently pay?Driver #2Name(Required) First Last Date of Birth MM slash DD slash YYYY Drivers LicensePhoneEmail OccupationRelationship(Required) Spouse Child Parent Domestic Partnership Other Driver #3Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Drivers License(Required)PhoneEmail OccupationRelationship to you(Required) Spouse Child Parent Domestic Partnership Other Driver #4Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Drivers License(Required)PhoneEmail OccupationRelationship to you(Required) Spouse Child Parent Domestic Partnership Other Driver #5Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Drivers License(Required)PhoneEmail OccupationRelationship to you(Required) Spouse Child Parent Domestic Partnership Other Vehicle #1Vehicle Year(Required)Make(Required)Model(Required)VINBusiness Use Yes No Rideshare or Delivery? Yes No Rental Reimbursement? Yes No Ownership Leased Financed Owned Level of Coverage Needed? Liability Only Full Coverage If Vehicle leased or financed must have full coverage.Vehicle #2Vehicle Year(Required)Vehicle Make(Required)Vehicle Model(Required)VINBusiness Use Yes No Rideshare or Delivery Yes No Rental Reimbursement Yes No Ownership Leased Financed Owned Level of Coverage Needed? Liability Only Full Coverage If Vehicle leased or financed must have full coverage.Vehicle #3Vehicle Year(Required)Vehicle Make(Required)Vehicle Model(Required)VINBusiness Use Yes No Rideshare or Delivery Yes No Rental Reimbursement Yes No Ownership Leased Financed Owned Level of Coverage Needed? Liability Only Full Coverage If Vehicle leased or financed must have full coverage.Vehicle #4Vehicle Year(Required)Vehicle Make(Required)Vehicle Model(Required)VINBusiness Use Yes No Rideshare or Delivery Yes No Rental Reimbursement Yes No Ownership Leased Financed Owned Level of Coverage Needed? Liability Only Full Coverage If Vehicle leased or financed must have full coverage.Vehicle #5Vehicle Year(Required)Vehicle Make(Required)Vehicle Model(Required)VINBusiness Use Yes No Rideshare or Delivery Yes No Rental Reimbursement Yes No Ownership Leased Financed Owned Level of Coverage Needed? Liability Only Full Coverage If Vehicle leased or financed must have full coverage. Tenant OnlyWhat type of Property?Single Family2-3 FamilyOtherOtherVacant Motorcycle/Slingshot/ATVName of Primary Driver First Last Vehicle Type(Required) Motorcycle Slingshot ATV Is Vehicle Used for Racing?(Required) Yes No Current Motorcycle License Yes No Has Driver Completed Safety Course? Yes No Year(Required)Make(Required)Model(Required)VIN UmbrellaIn order to purchase an umbrella liability policy you must have auto liability limits of at least 250/500/250 and home/renters personal liability of at least $300,000.(Required) I understand that if the current liability limits on my auto and home/renters policies do not meet those minimums I will not be eligible to purchase an umbrella liability policy. How many homes do you own?This includes primary, secondary, vacation, rental and investment properties.How many home/renters claims have you made in the last 5 years?How many vehicles do you own?How many auto claims have you made in the last 5 years?Any drivers on your auto policy have an at-fault accident in the last 5 years? Yes No Do you own any of the following items? Boat/Yacht Motorcycle ATV Vacant Land Business Boat InformationWhere is boat stored? Primary Residence Marina - Slip Marina - Dry Stack Other Year(Required)Make(Required)Model(Required)Hull NumberMotor Type(Required) Inboard Outboard Top Speed (MPH)Boat Length(Required)Boat is used for racing? Yes No Do you own a boat trailer? Yes No Recreational VehicleRV Type 5th Wheel Motorcoach Other Year(Required)Make(Required)Model(Required) Please add any additional information herePlease upload current policy documents if you have them available.Max. file size: 100 MB. I agree that Sica Insurance may contact me via phone call, email and text message.(Required)YesNoCAPTCHA
