I will run all the insurance quotes by each of
the insurance companies that our company represents and choose the best
insurance to fit my customer needs.
我将从众多的保险公司里筛选出来最适合顾客需要的、最使顾客省钱的保险计划。
For residential we do following insurance（我们受理的险种有）:
Auto（汽车保险）, Boat（船只保险）, Motorcycle （摩托车保险）
Homeowner（住房保险）, Renter（租赁人保险）, Fire（房主保险）
Mobile Home （活动房保险）, Earthquake（地震保险）
Personal Umbrella （加大责任范围保险）
Health （健康保险）, Life （人寿保险）
Discount for （对于如下情况有优惠）:
Multi-vehicles (多辆汽车), Auto & Home Packages (汽车和房屋绑定)
Good Students (优秀学生), Burglar Alarm (房屋报警系统 ), Security System (汽车安全装置)
Questionnaire for Personal Property and Auto Insurance Quote
【房屋及汽车保险报价所需资料】
Applicant Information（申请人信息）:
Full Name: __________________
Mailing Address: ______________________________________________
City _____________ State ________ Zip Code ________
Phone ________________ Cell _________________ Fax ____________________
Email ______________________________
What date do want this coverage to begin? ___________________
Occupation ____________________________________________
Do you own or rent your current home? _______________________
If so, please provide the name of your
homeowners insurance company and policy number:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Home / Landlord Dwelling Information （房屋信息）:
| Dwelling #1 |
Dwelling #2 | Dwelling #3 | |
| County |
|||
| Parcel Number |
|||
| Address: |
|||
| Property Type*: |
SF / TH / C |
SF / TH / C | SF / TH / C |
| Year Built:: | |||
| # of Stories: | |||
| Square Footage: |
|||
| Construction of Building: |
|||
| Year updated - roof: |
|||
| Year updated - electric: |
|||
| Year updated - HVAC |
|||
| Year updated - Plumbing |
|||
| Smoke Detectors: |
|||
| Fire Extinguishers: |
|||
| Alarm: |
Local or Central | Local or Central | Local or Central |
| Mortgagee** |
Yes or No |
Yes or No |
Yes or No |
| Additional Insured Name |
|||
| Coverage Limit |
|||
| Special personal properties' value: (Such as Gold, Silver, Jewellery...) |
|||
| Annual Deductible |
$250 $500 $1000 or more |
$250 $500 $1000 or more | $250 $500 $1000 or more |
* SF - Single Family Home TH - Town House C - Condominium
** Mortgagee information
| Name |
|
| Address |
|
| Loan Number |
| Name |
|
| Address |
|
| Loan Number |
Drivers' information（驾驶者信息）:
| Driver #1 |
Driver # 2 | Driver # 3 | Driver # 4 |
|
| Full name: |
||||
| Date Birth: |
||||
| Gender: |
||||
| Marital Status |
||||
| Level of Education: |
||||
| License State: |
||||
| Driver's license #: |
||||
| SSN: |
||||
| Claim for past 5 years: Please explain if you have ( date, what happened in detail) |
Vehicles' information （汽车信息）:
| Vehicle #1 |
Vehicle #3 | Vehicle #3 | |
| Year: |
|||
| Make: |
|||
| VIN # |
|||
| Assigned Driver | |||
| Vehicle Use: |
Pleasure School Work |
Pleasure School Work |
Pleasure School Work |
| Mileage One Way |
|||
| Days per Week drive to work/school |
|||
| Anti-Theft |
Yes or No |
Yes or No |
Yes or No |
Prior Auto Insurance Information （以前六个月的保险信息）:
Carrier （保险公司及保单有效期）:
| Prior Carrier: |
|
| Policy Number: |
|
| Expiration Date: |
|
| Months with this Carrier: |
Coverages（保险额度）:
| Coverage Limit |
|
| Bodily Injury Liability (第三方人身损伤） |
$25,000 (per person) / $50,000 (Per accident) $50,000 (per person) / $100,000 (Per accident) $100,000 (per person) / $300,000 (Per accident) $250,000 (per person) / $500,000 (Per accident) |
| Property Damage liability (第三方车辆及财物损伤） |
$10,000 $25,000 $50,000 $100,000 $250,000 |
| Death Indemnity （死亡补偿） |
$75,00 Insured and Spouse $75,00 Insured only $15,000 Insured and Spouse $75,000 Insured only |
| Personal Injury Protection （人身伤残） |
$10,000 Per person $35,000 Per person |
| Underinsured Motorist Bodily Injury （驾驶保险不足 - 保 己方人身） |
$25,000 (per person) / $50,000 (Per accident) $50,000 (per person) / $100,000 (Per accident) $100,000 (per person) / $300,000 (Per accident) $250,000 (per person) / $500,000 (Per accident) |
| Underinsured Motorist Property Damage （驾驶保险不足 - 保 己方车辆） |
$10,000 $25,000 $50,000 $60,000 $100,000 $300,000 $500,000 |
| Comprehensive Deductible （非碰撞保险，例如：车辆被偷被盗，挡风玻璃破碎...， - 保己方车辆。 赔偿金 = 车损总额 - 自付部分， 自付部分越高保险费用越低。） |
$100 $100 w/Glass $250 $250 w/Glass $500 $500 w/Glass $1,000 $1,000 w/Glass $2,000 $2,000 w/Glass |
| Collision Deductible （碰撞保险- 保己方车辆。 赔偿金 = 车损总额 - 自付部分， 自付部分越高保险费用越低。） |
$250 $500 $1,000 $2,000 |
| Loss of Use （由于法身车祸，车子不能正常使用，在修理期间保险公司提供的租车费用，必须有碰撞保险 |
$22 Per day for no more than 30 days $50 Per day for no more than 30 days |
| Roadside Assistance （拖车保险） |
Yes or not |