Name: Near Me Insurance
Price range: $$

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Name

This field is for validation purposes and should be left unchanged.

Types of Insurance*

Bundle Home and Auto

Home

Auto

Life

Umbrella

Valuable Items

Motorcycle

Boat

RV Trailer or Camper

Golf Cart

Renters

Date Policies Should Start

Primary Applicant

Primary Insured Name*

First Last

Email*

Phone*

SMS Consent

By checking this box, you consent to receive text messages from Near Me Insurance at the mobile number provided regarding your insurance inquiries, quotes, and policy updates and promotional/marketing messages. Consent is not a condition of purchase. Message and data rates may apply. Message frequency varies. Reply HELP for help or STOP to cancel. View our Privacy Policy and Terms of Service

Date of Birth*

Month

Day

Year

Gender*

Drivers License Number*

Drivers License State*

Motorcycle Endorsement?

Yes

Marital Status

Education Level

Occupation

Is there a Co-Applicant?

Yes

Co-Applicant

Co-Insured Name*

First Last

Co-Insured Date of Birth*

Month

Day

Year

Co-Insured Gender*

Co-Insured Email

Co-Insured Phone

Co-Insured Drivers License Number

Co-Insured Drivers License State

Co-Insured Motorcycle Endorsement?

Yes

Co-Insured Education Level

Co-Insured Occupation

Bundle Your Policies

Bundling your insurance policies home/renters, auto, and umbrella as a package can save you money, and gives you more access to better carriers and better rates. Its a great way to maximize coverage and value.

Would you like to bundle your policies?

Yes, bundle my Homeowners, Auto, Umbrella

Yes, bundle my Renters and Auto

No thanks

Current Address

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Current Address*

Same as Mailing Address

Street Address Address Line 2 City State ZIP Code

Property Address

Property Address*

Street Address Address Line 2 City State ZIP Code

Property Map

Homeowners Information

Type of Home*

Primary Use For Home*

How many weeks per year will the property be rented?

How long will the property be vacant at one time?

Is there a caretaker?

Yes

Primary Occupancy*

Is property titled in a name Other Than your personal name(s)?*

Example: Trust, LLC, Corporation, Partnership, etc.

Yes

Name on Title of Property*

Is this a New Purchase?

Yes

Purchase Date*

Purchase Price

Will there be a Mortgage?

Yes

Are there multiple dwellings on this property?

Yes

Additional Property Coverage Interests

None

Flood

Earthquake

Hurricane

Do you currently have a homeowners insurance policy?

Yes

Name of current home insurance company

Renters Information

Do you currently have a renters insurance policy?

Yes

Name of current renters insurance company

Dogs

Do you have dog(s)?

Yes

Breed(s) of Dog(s)

Any dogs have bite history?

Yes

Home Information

Is home newly built?

Yes

Home Currently Under Construction?*

Yes

Year Built

Square Feet

# of Stories

# of Bedrooms

# of Full Baths

# of Partial Baths

Primary Heating Type

Construction Type

Roof Type

Foundation Type

Garage Type

Garage Number of Vehicles

Security System

Has Fireplace?

Yes

Has Pool?

Yes

Pool Type

In Ground

Above Ground

Is Pool Fenced?

Yes

Does pool have a diving board?

Yes

Has there been any updates to the Roof, Plumbing, Heating, or Electrical?

Yes

Roof Update Year

Roof Update Level

Plumbing Update Year

Plumbing Update Level

Heating Update Year

Heating Update Level

Electrical Update Year

Electrical Update Level

Solar Panels?

Yes

Number of Solar Panels

Value of Solar Panels

Does home have any detached structures?

Yes

What types of detached structures?

Guest House

Pool House

Shed

Workshop

Deck

Other

Other type of detached structure

Any trampoline?

Yes

Photos of Home (Optional)

If you would like to attach any pictures of your home inside and/or outside, please do so here.

Drop files here or

Max. file size: 3 MB, Max. files: 6.

Valuable Items

Most home insurance policies allow you to schedule valuable items to your policy such as jewelry, fine art, firearms, antiques, bikes, cameras, certain electronics, collectibles, musical instruments, silverware, etc. If you would like to include any of these items, please do so below. If an item is ineligible for scheduling to your policy we will let you know.

Do you have any items you would like to schedule to your homeowners policy?

6. Driver Name*

First Last

6. Driver Date of Birth*

6. Gender*

6. Driver License #

6. Drivers License State

6. Relationship to Insured

Vehicle 1

1. VIN

1. Year*

1. Make*

1. Model*

1. Estimated Annual Miles

1. Primary Use

1. Ownership

Owned

Leased

1. Vehicle Financed

Yes

1. Preferred COMPREHENSIVE Deductible

1. Preferred COLLISION Deductible

1. Name of Primary Driver

Add 2nd Vehicle

Add a Vehicle

Vehicle 2

2. VIN

2. Year*

2. Make*

2. Model*

2. Estimated Annual Miles

2. Primary Use

2. Ownership

Owned

Leased

2. Vehicle Financed

Yes

2. Preferred COMPREHENSIVE Deductible

2. Preferred COLLISION Deductible

2. Name of Primary Driver

Add 3rd Vehicle

Add a Vehicle

Vehicle 3

3. VIN

3. Year*

3. Make*

3. Model*

3. Estimated Annual Miles

3. Primary Use

3. Ownership

Owned

Leased

3. Vehicle Financed

Yes

3. Preferred COMPREHENSIVE Deductible

3. Preferred COLLISION Deductible

3. Name of Primary Driver

Add 4th Vehicle

Add a Vehicle

Vehicle 4

4. VIN

4. Year*

4. Make*

4. Model*

4. Estimated Annual Miles

4. Primary Use

4. Ownership

Owned

Leased

4. Vehicle Financed

Yes

4. Preferred COMPREHENSIVE Deductible

4. Preferred COLLISION Deductible

4. Name of Primary Driver

Add 5th Vehicle

Add a Vehicle

Vehicle 5

5. VIN

5. Year*

5. Make*

5. Model*

5. Estimated Annual Miles

5. Primary Use

5. Ownership

Owned

Leased

5. Vehicle Financed

Yes

5. Preferred COMPREHENSIVE Deductible

5. Preferred COLLISION Deductible

5. Name of Primary Driver

Add 6th Vehicle

Add a Vehicle

Vehicle 6

6. VIN

6. Year*

6. Make*

6. Model*

6. Annual Miles Driven

6. Primary Use

6. Ownership

Owned

Leased

6. Vehicle Financed

Yes

6. Preferred COMPREHENSIVE Deductible

6. Preferred COLLISION Deductible

6. Name of Primary Driver

Add 7th Vehicle

Add a Vehicle

Vehicle 7

7. VIN

7. Year*

7. Make*

7. Model*

7. Annual Miles Driven

7. Primary Use

7. Ownership

Owned

Leased

7. Vehicle Financed

Yes

7. Preferred COMPREHENSIVE Deductible

7. Preferred COLLISION Deductible

7. Name of Primary Driver

Add 8th Vehicle

Add a Vehicle

Vehicle 8

8. VIN

8. Year*

8. Make*

8. Model*

8. Annual Miles Driven

8. Primary Use

8. Ownership

Owned

Leased

8. Vehicle Financed

Yes

8. Preferred COMPREHENSIVE Deductible

8. Preferred COLLISION Deductible

8. Name of Primary Driver

Add 9th Vehicle

Add a Vehicle

Vehicle 9

9. VIN

9. Year*

9. Make*

9. Model*

9. Annual Miles Driven

9. Primary Use

9. Ownership

Owned

Leased

9. Vehicle Financed

Yes

9. Preferred COMPREHENSIVE Deductible

9. Preferred COLLISION Deductible

9. Name of Primary Driver

Add 10th Vehicle

Add a Vehicle

Vehicle 10

10. VIN

10. Year*

10. Make*

10. Model*

10. Annual Miles Driven

10. Primary Use

10. Ownership

Owned

Leased

10. Vehicle Financed

Yes

10. Preferred COMPREHENSIVE Deductible

10. Preferred COLLISION Deductible

10. Name of Primary Driver

Golf Cart(s) Information

Golf Cart (Serial Number)

Golf Cart (Year)*

Golf Cart (Make)*

Golf Cart (Model)*

Preferred COMPREHENSIVE Deductible

Preferred COLLISION Deductible

Is golf cart financed?

Yes

Is golf cart registered for street use?

Yes

Where will the golf cart be stored?

Garage

Carport

Driveway

Other

Describe other storage location

Add 2nd Golf Cart

Add another Golf Cart

Golf Cart 2

Golf Cart 2 (Serial Number)

Golf Cart 2 (Year)*

Golf Cart 2 (Make)*

Golf Cart 2 (Model)*

Preferred COMPREHENSIVE Deductible

Preferred COLLISION Deductible

Is golf cart financed?

Yes

Is golf cart registered for street use?

Yes

Where will the golf cart be stored?

Garage

Carport

Driveway

Other

Describe other storage location

Special Motorcycle Coverages

Enhanced Injury Protection

Yes

Physical Damage

Actual Cash Value

None - Liability Only

Roadside Assistance

None

Roadside

Roadside w/ Trip Interruption

Carried Contents

None

$1,000

$2,000

$3,000

Accessories Coverage

Safety & Riding Apparel

Transport Trailer Coverage?

Yes

Trailer Value

Boat Information

Serial Number

Year*

Make*

Model*

Hull ID Number

Boat Registration Number

This is the ID number assigned to your boat by the state.

Hull Material

Number of Motors

Propulsion Type

Max Horsepower

Max Speed

Current Value

Fishing Equipment Coverage

Insure the Trailer?

Yes

RV, Trailer, or Camper Information

Year*

Make*

Model*

VIN

Length (in feet)*

Please enter a number greater than or equal to 2.

Year Purchased

Value (estimated ACV)

Garaging Zipcode

Number of days RV used per year

Original Owner?

Yes

Is there a lienholder?

Yes

RV Lienholder Name

Is RV parked at a single location year round?

Yes

Is RV rented commercially or used for business purposes?

Yes

Is RV rented out to others?

Yes

Is RV taken to/from work or used at a work location?

Yes

Primary Applicant Life Insurance

Amount of Coverage*

Duration*

Current Height (feet and inches)

Current Weight (lbs)

Nicotine User?*

Yes

Employer

Annual Salary

Household Income

Any known health issues?

Prescription Medications (name, dosage, frequency)

Have you been hospitalized in the last 5 years?

Yes

Family Members

Age of Parents & Siblings

Any known diseases

Age of Death (if deceased)

Cause of Death

Click the (+) icon to add additional family members.

Beneficiaries

Name

Date of Birth

Relationship to Applicant

Address

% of share

Click the (+) icon to add additional beneficiaries.

Does Co-Applicant need life insurance?*

Yes

Co-Applicant Life Insurance

Co-Applicant Amount of Coverage*

Duration*

Current Height (feet and inches)

Current Weight (lbs)

Nicotine User?*

Yes

Employer

Annual Salary

Any known health issues?

Prescription Medications (name, dosage, frequency)

Has co-applicant been hospitalized in the last 5 years?

Yes

Family Members

Age of Parents & Siblings

Any known diseases

Age of Death (if deceased)

Cause of Death

Click the (+) icon to add additional family members.

Beneficiaries

Name

Date of Birth

Relationship to Applicant

Address

% of share

Click the (+) icon to add additional beneficiaries.

Umbrella Coverage Information

Number of Properties

Number of Vehicles

Number of Watercraft

Number of Drivers

Number of Drivers (under age 25)

Number of Drivers (over age 75)

Liability Limit

Wrapping Up

Any Claims in the Past Three (3) Years?

Yes

Please describe past claims

Any lapse in Home insurance in the past year?

Yes

Not Applicable

Any lapse in Auto insurance in the past year?

Yes

Not Applicable

Do you have any auto insurance currently?

Yes

Name of current auto insurance company

Additional Comments

Attach Documents, Images, or Other Files

Drop files here or

Max. file size: 20 MB.

Would you like a quote from a specific agent?

How were you referred to us?

Would you like to create a user account?

Yes

Username*

Only letters and numbers.

Password*

Enter Password Confirm Password

Consent*

The information you provide on this form, including any driver's license, financial, or health-related information, will be used to obtain insurance quotes and process your request. We do not sell this information. California residents have the right to limit our use of sensitive personal information — see our Privacy Policy for details, or visit Your California Privacy Choices to submit a request.

I agree to the collection and use of my information as described in the Privacy Policy for the purpose of obtaining an insurance quote.

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Primary Applicant

Co-Applicant

Bundle Your Policies

Current Address

Property Address

Homeowners Information

Renters Information

Dogs

Home Information

Valuable Items

Additional Drivers

Additional Driver 1

Additional Driver 2

Additional Driver 3

Additional Driver 4

Additional Driver 5

Additional Driver 6

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

Vehicle 7

Vehicle 8

Vehicle 9

Vehicle 10

Golf Cart(s) Information

Golf Cart 2

Special Motorcycle Coverages

Boat Information

RV, Trailer, or Camper Information

Primary Applicant Life Insurance

Co-Applicant Life Insurance

Umbrella Coverage Information

Wrapping Up

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