Personal Lines Quote Request Form

Additional Information - Step 1 of 4

Thank you for your interest in getting an insurance quote from Wood-Wilson Company! How did you hear about us? *

Referral from existing client
One of your agents sent me here
Other

If you checked other, please let us know how you heard about us. *

Applicant Name *

First

Middle

Last

You are the applicant, unless you are completing this form on behalf of someone else.

Applicant's Date of Birth *//

Applicant Social Security Number

Applicant's Marital Status *

Applicant's Occupation *

Applicant's Education Level *

Would you like to list an additional named insured, called the co-applicant, on your policies? Your spouse or domestic partner should be a co-applicant. *

Other people, aside from your spouse or domestic partner might need to be a co-applicant. For example, if you have a parent or child who co-owns a house or car with you, they would need to be a co-applicant on your homeowners or auto policy.

Co-applicant Name *

First

Last

Co-applicant's Date of Birth *//

Co-applicant Social Security Number

Co-applicant's Marital Status *

Co-applicant's Relationship to Applicant *

Co-applicant's Relationship to Applicant Detail *

Describe how the co-applicant is related to the applicant.

Co-applicant's Occupation *

Co-applicant's Education Level *

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Current Address County *

Is your mailing address different than your current address? *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Number of Years at Current Address *

Prior Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Confirm Email

My home is *

Owned
Rented

Credit Score Authorization *

All insurance carriers use credit scoring as part of the quoting process. By clicking Yes, you authorize Wood-Wilson Company to quote your insurance and understand that your credit score will be used in the rating process. We will not be able to offer you a quote without your

I would like a quote for *

Homeowners & Auto Insurance
Auto Insurance Only
Homeowners Insurance Only

We can offer you our best pricing if you bundle your auto and homeowners insurance with us.

Auto Insurance General Information

Auto Policy Requested Effective Date *//

Most insurance companies offer a discount if the effective date of the new policy is at least seven days from the current date.

Current Auto Insurance Carrier *

Current Auto Liability Limits *

Tell us what your current bodily injury and property damage liability limits are. Most policies have split limits, which means there are separate limits for bodily injury per person and per accident and for property damage. Some policies have one limit for everything, called a combined single limit.

Current Policy Expiration Date *//

When does your current policy end or renew? If you do not currently have coverage in force, please put the date your prior policy cancelled.

Requested Bodily Injury Limits *

Our agency recommends that everyone carry at least 100,000 per personal/300,000 per accident. If you need limits that are higher than $500,000, please make note of that at the end of this quote form.

Requested Property Damage Limits *

Requested Uninsured Bodily Injury Limits *

We usually recommend matching these limits to your liability limits. You may also reject this coverage entirely.

Requested Uninsured Property Damage Limits *

Personal Injury Protection *

This provides coverage for injuries to you and your passengers in the event of an accident.

Medical Payments *

This is similar to personal injury protection. Most policies have either medical payments or personal injury protection.

Some auto carriers offer a discount if you install an app on your phone or a device in your car that monitors your driving habits. Are you interested in this?

No
Yes
Maybe - I'd like to see how much I could save and get some more information.

Have you filed any auto claims in the past five years? *

Auto Claims History *

Tell us about any auto insurance claims you have filed within the past five years. List the approximate date of loss and what happened (for example, hail damage or someone ran a red light and hit my car and took off). We will run loss history reports, and the information you provide here will help us reconcile the reports.

Have you or any driver covered on your auto policy received a citation (ticket) in the past three years? *

If you received a citation and took defensive driving or other steps to keep the citation from going on your record, you may select "no."

Citation Information

Tell us when and for what you or another driver received the citation(s).

Vehicle Information

Vehicle #1 VIN (Vehicle Identification Number) *

Vehicle #1 Model Year *

Vehicle #1 Make and Model *

Was vehicle #1 purchased within the last 90 days?

In what condition was vehicle #1 it was purchased?

New
Used

How is vehicle #1 primarily used? *

Many of us enjoy driving our cars, but in this case, "pleasure" means that you don't drive your vehicle to and from work or school. "Commute" means you drive your vehicle to and from work or school three or more days per week. "Business" means you use your vehicle to conduct business, hauling stuff or driving clients around town. "Farm" means that your vehicle is kept on your farm and used in the scope of running the farm. (If you have a farm, let us quote your farm and ranch owners insurance!)

How many miles a year is vehicle #1 driven? *

What is the odometer reading for vehicle #1?

Vehicle #1 Collision Coverage Deductible *

Collision provides coverage for your vehicle if you have an accident that is your fault. The deductible is how much you'll have to pay out of pocket. The higher the deductible, the lower the premium.

Vehicle #1 Comprehensive/Other Than Collision Deductible *

Comprehensive coverage, also called other than collision coverage, covers your vehicle for non-collision occurrences, such has theft, fire, hail, and vandalism.

Vehicle #1 Rental Reimbursement Coverage *

Rental reimbursement coverage provides you with a rental vehicle if your car is disabled due to an incident coverage by your insurance policy. The first number is a daily limit, and the second number is the maximum amount of coverage available.

Vehicle #1 Towing & Labor/Roadside Assistant Coverage *

Yes, I'd like this coverage
No, I don't want this coverage

How many additional vehicles do you need to add? *

One
Two
Three
None; I'm done with vehicles!

If you have more than four vehicles, please complete the information for the first four and note the remaining vehicle information at the end of this form.

Vehicle #2 VIN (Vehicle Identification Number) *

Vehicle #2 Model Year *

Vehicle #2 Make and Model *

Was vehicle #2 purchased within the last 90 days?

In what condition was vehicle #2 it was purchased?

New
Used

How is vehicle #2 primarily used? *

How many miles a year is vehicle #2 driven? *

What is the odometer reading for vehicle #2?

Vehicle #2 Collision Coverage Deductible *

Collision provides coverage for your vehicle if you have an accident that is your fault. The deductible is how much you'll have to pay out of pocket. The higher the deductible, the lower the premium.

Vehicle #2 Comprehensive/Other Than Collision Deductible *

Comprehensive coverage, also called other than collision coverage, covers your vehicle for non-collision occurrences, such has theft, fire, hail, and vandalism.

Vehicle #2 Rental Reimbursement Coverage *

Vehicle #2 Towing & Labor/Roadside Assistant Coverage *

Yes, I'd like this coverage
No, I don't want this coverage

Vehicle #3 VIN (Vehicle Identification Number) *

Vehicle #3 Model Year *

Vehicle #3 Make and Model *

Was vehicle #3 purchased within the last 90 days?

In what condition was vehicle #3 it was purchased?

New
Used

How is vehicle #3 primarily used? *

How many miles a year is vehicle #3 driven? *

What is the odometer reading for vehicle #3?

Vehicle #3 Collision Coverage Deductible *

Collision provides coverage for your vehicle if you have an accident that is your fault. The deductible is how much you'll have to pay out of pocket. The higher the deductible, the lower the premium.

Vehicle #3 Comprehensive/Other Than Collision Deductible *

Comprehensive coverage, also called other than collision coverage, covers your vehicle for non-collision occurrences, such has theft, fire, hail, and vandalism.

Vehicle #3 Rental Reimbursement Coverage *

Vehicle #3 Towing & Labor/Roadside Assistant Coverage *

Yes, I'd like this coverage
No, I don't want this coverage

Vehicle #4 VIN (Vehicle Identification Number) *

Vehicle #4 Model Year *

Vehicle #4 Make and Model *

Was vehicle #4 purchased within the last 90 days?

In what condition was vehicle #4 it was purchased?

New
Used

How is vehicle #4 primarily used? (copy) *

How many miles a year is vehicle #4 driven? *

What is the odometer reading for vehicle #4?

Vehicle #4 Collision Coverage Deductible *

Collision provides coverage for your vehicle if you have an accident that is your fault. The deductible is how much you'll have to pay out of pocket. The higher the deductible, the lower the premium.

Vehicle #4 Comprehensive/Other Than Collision Deductible *

Comprehensive coverage, also called other than collision coverage, covers your vehicle for non-collision occurrences, such has theft, fire, hail, and vandalism.

Vehicle #4 Rental Reimbursement Coverage *

Vehicle #4 Towing & Labor/Roadside Assistant Coverage *

Yes, I'd like this coverage
No, I don't want this coverage

Driver Information

Which vehicle do you (the applicant) drive the most? *

Your (the applicant's) Drivers License Number *

How many years have you (the applicant) had your driver's license?

This is the total number of years you're been licensed to drive, not the number of years your current license has been in force.

Which vehicle does the co-applicant drive the most? *

Co-applicant's Drivers License Number and State *

How many years has the co-applicant had a driver's license? (copy)

This is the total number of years the co-applicant has been licensed to drive, not the number of years the current license has been in force.

How many additional drivers do you need to add? *

If you have more than three additional drivers to add, please enter the information for the first three additional drivers here and note the additional driver information at the end of this form.

Additional Driver #1 *

First

Last

Additional Driver #1 Date of Birth *//

Additional Driver #1 Driver's License Number and State *

How many years has driver #1 had a driver's license?

This is the total number of years driver #1 has been licensed to drive, not the number of years the current license has been in force.

Additional Driver #1 Occupation *

Which vehicle does additional driver #1 drive the most? *

If you have more drivers than vehicles and driver #1 is not the principal operator for any vehicle, you may indicate that here. Note that by the end this application, you'll need to have assigned each vehicle to at least one principal operator so that we can give you an accurate rate quote.

Additional Driver #2 *

First

Last

Additional Driver #2 Date of Birth *//

Additional Driver #2 Driver's License Number and State *

How many years has driver #2 had a driver's license?

This is the total number of years driver #2 has been licensed to drive, not the number of years the current license has been in force.

Additional Driver #2 Occupation *

Which vehicle does additional driver #2 drive the most? *

If you have more drivers than vehicles and driver #2 is not the principal operator for any vehicle, you may indicate that here. Note that by the end this application, you'll need to have assigned each vehicle to at least one principal operator so that we can give you an accurate rate quote.

Additional Driver #3 *

First

Last

Additional Driver #3 Date of Birth *//

Additional Driver #3 Driver's License Number and State *

How many years has driver #3 had a driver's license?

This is the total number of years driver #3 has been licensed to drive, not the number of years the current license has been in force.

Additional Driver #3 Occupation *

Which vehicle does additional driver #3 drive the most? *

If you have more drivers than vehicles and driver #3 is not the principal operator for any vehicle, you may indicate that here. Note that by the end this application, you'll need to have assigned each vehicle to at least one principal operator so that we can give you an accurate rate quote.

Homeowners Insurance General Information

Homeowners Policy Requested Effective Date *//

Most insurance companies offer a discount if the effective date of the new policy is at least seven days from the current date.

Current Homeowners Insurance Carrier *

Current Homeowners Policy Expiration Date *//

Information About Your Home

Type of Home *

House
Condo
Apartment

Year Built *

Foundation Type *

Slab
Pier & Beam (Crawlspace)

Exterior Construction Material *

Examples: brick veneer, wood siding, vinyl siding, fiber cement (Hardie plank) siding, stucco, EIFS.

Number of Families *

One (single family home)
Two (duplex)

Purchase Date *//

Square Footage *

Living area only; do not include the garage.

Number of Stories *

Number of Full Bathrooms *

Number of Half Bathrooms *

Roof Material *

Examples: asphalt shingles, architectural shingles, tile, wood shakes, standing seam metal

Number of Roof Layers *

Year of Roof Replacement *

If the year of roof replacement is the same as the year your home was built, please enter that year here.

Do you have a swimming pool? *

Do you have any of the following? *

A fence with a locked gate around the pool
A diving board
A pool slide

Do you have any dogs? *

Number and Description of Dogs *

We like animals! Tell us about your dogs. How many do you have? What breed of dog(s)? Have they ever been naughty and bitten anyone?

Do your home have a monitored alarm system? *

Yes, monitored for burglary and fire
Yes, monitored for burglary only
No

A monitored alarm system is one monitored by a third-party company, like ADT, or the police.

Home Smart Features

Tell us about any smart features you have in your home, such as front door cameras, smart water heater leak detectors, smart smoke alarms, etc.

Home Renovations

Tell us about any renovations that have been done to your home. We'd like to know what you did and when. For older homes, we'd like to know what updates to the heating, plumbing and electrical systems have been made.

Special Features

Please tell us about any special features of your home that we haven't already asked about. Special features include specialty rooms, such as a media room/home theater; a fence with gate surrounding the house; 24-hour community security patrol and/or a gated community; protection systems such as lightning protection or a water flow alarm. Be sure to include as many details as you can.

Have you filed any homeowners claims in the past seven years? *

Homeowners Claims History *

Tell us about any homeowners insurance claims you have filed within the past seven years. List the approximate date of loss and what happened (for example, hail damage to the roof or water heater leak). Also please indicate whether or not the damage to your home has been repaired. We will run loss history reports, and the information you provide here will help us reconcile the reports.

My homeowners association carries property insurance for the exterior of my home. *

Homeowners Insurance Coverages

Dwelling Coverage *

If this home is a new purchase, please input the purchase price here.

Dwelling or Additions/Alterations Coverage *

If this home/condo is a new purchase, please input the purchase price here.

Personal Property Coverage

Other Structures Coverage

Loss of Use Coverage

Personal Liability Coverage

Medical Payments

Wind/Hail Deductible *

Most carriers require a 1% minimum wind/hail deductible.

All Peril Deductible *

Most carriers require $1,000 minimum but 1% is the most common deductible.

Would you like a quote for an umbrella? *

An umbrella or excess liability policy provides additional liability coverage. It sits over your auto liability and homeowners liability, covering you like a regular umbrella covers you during a rainstorm! We'll provide you with a quote for $1 million based on your auto and homeowners information. When we discuss our proposal with you, we will discuss tailoring the coverage to your specific needs.

Do you have any valuable items you'd like to schedule?

We can insure any valuable and/or collectible items you have on a valuable articles schedule. If you have any items you'd like to schedule, please list the items here, including a description and value.

Do you own a secondary residence, rental properties, motorcycles, watercraft, or other recreational vehicles?

Guess what? We can insure these too!

Additional Information and Comments

Do you have anything to add? If you have additional vehicle and/or driver information, please enter it here.

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