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Producer Quote Options Form - Personal Lines
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What is the producer's name?
What is the producer's name?
First
Last
Enter the producer's email address:
Enter the producer's email address:
Please enter the quote number and/or insured name for which you are requesting quote updates/changes.
Please enter the quote number and/or insured name for which you are requesting quote updates/changes.
Please select the quote(s)/aspects of the quote(s) you would like to receive updates for:
Please select the quote(s)/aspects of the quote(s) you would like to receive updates for:
Policy level (Named insured, Mailing Address, etc...)
Homeowners / Condominium / Cooperative / Renters
Valuable Articles
Automobile
Umbrella
Billing Options
Enter the named insured as you would like it to appear on the policy.
Enter the named insured as you would like it to appear on the policy.
Please enter the mailing address you would like on the policy.
Please enter the mailing address you would like on the policy.
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Homeowners / Condominium / Cooperative / Renters
Please select the aspects of the homeowners quote you would like updated.
Please select the aspects of the homeowners quote you would like updated.
Policy details (Named insured, Mailing Address, Additional insured, mortgagee clause, etc...)
Core Coverage limits (Dwelling, Other Structures, Personal Property, Liability, etc...)
Deductible options
Optional coverages (Equipment breakdown, Cyber, Earthquake, Flood, etc...)
Credits / Discounts
Billing Options
Please select the Homeowners policy details you would like to have updated.
Please select the Homeowners policy details you would like to have updated.
Additional Insured
Mortgage Clause
Enter the additional insured as you would like it to appear on the policy.
Enter the additional insured as you would like it to appear on the policy.
Enter the mortgagee clause for this homeowners quote.
Enter the mortgagee clause for this homeowners quote.
Enter the dwelling/additions & alterations coverage limit:
Enter the dwelling/additions & alterations coverage limit:
Enter the other structures coverage limit:
Enter the other structures coverage limit:
Enter the personal property coverage limit:
Enter the personal property coverage limit:
Enter the Loss of Use coverage limit:
Enter the Loss of Use coverage limit:
Select the desired Liability coverage limit(s).
Select the desired Liability coverage limit(s).
$100,000
$300,000
$500,000
$1,000,000
$2,000,000
$3,000,000
$5,000,000
$10,000,000
Select the desired Medical Payments coverage limit(s).
Select the desired Medical Payments coverage limit(s).
$1,000
$2,000
$5,000
$10,000
$25,000
$50,000
$100,000
All other perils deductible options: (Hold the Shift key down to select multiple options)
All other perils deductible options: (Hold the Shift key down to select multiple options)
$500
$1,000
$2,500
$5,000
$7,500
$10,000
$25,000
$50,000
$100,000
$250,000
Please selection the optional coverages you would like added to this quote.
Please selection the optional coverages you would like added to this quote.
Flood
Excess Flood
Cyber liability
Equipment breakdown
Mold/Fungi
Earthquake
Hurricane
Increased Other Structures
Sink Hole
Please select the credits/discounts you would like applied to this quote.
Please select the credits/discounts you would like applied to this quote.
Central Station Fire Alarm
Central Station Burglar Alarm
Central Station Low Temperature Monitor
Stand-by Back-up Generator
Water Leak Detection
Water Leak Detection with Centrally Monitored Alarm
Automatic Shut-Off Valve
24-hour signal conitnuity
24-hour professionally monitored video surveillance
Full-time Live-in Caretaker
Gas Leak Detection
Seismic Shut-off Valve
Lightning Protection System
Dry Fire Hyrdant
Gated House
Gated Community
Perimeter Fencing
LEED Certified House
Permanently Installed Safe
Flood vents
Please select the desired billing option for this homeowners/condominium/cooperative quote:
Please select the desired billing option for this homeowners/condominium/cooperative quote:
Insured billed
Agency billed
Mortgagee billed
Enter any other changes you would like this quote below.
Enter any other changes you would like this quote below.
Valuable Articles
Which aspects of the valuable articles quote would you like updated?
Which aspects of the valuable articles quote would you like updated?
Coverage amounts/details (Category amounts, Scheduled items, etc...)
Credits / Discounts
Please enter the changes/updates you would like made to the valuable articles quote below.
Please enter the changes/updates you would like made to the valuable articles quote below.
Select the credits / discounts you would like added to/updated on this valuable articles quote.
Select the credits / discounts you would like added to/updated on this valuable articles quote.
Permanently installed in-home safe
Large schedule premium modification
Central station burglar alarm
Other
Please enter the make, model and serial number for the safe.
Please enter the make, model and serial number for the safe.
Please enter the credits / discounts you would like added to/updated on this valuable articles quote.
Please enter the credits / discounts you would like added to/updated on this valuable articles quote.
Automobile
Please select the aspects of the Automobile quote you would like updated.
Please select the aspects of the Automobile quote you would like updated.
Policy details (Loss payee, Additional drivers, etc...)
Core Coverage limits (Agreed Values, Liability, Uninsured/Underinsured, Medical Payments etc...)
Deductible options
Optional coverages (OEM parts, Agreed Value, Vehicle customization, Rental reimbursement, Towing, etc...)
Credits / Discounts
Billing details
Please select the policy details you would like to update.
Please select the policy details you would like to update.
Loss Payee/Additional Insured
Additional Driver(s)
Please enter the loss payee/lien holder information you would like updated.
Please enter the loss payee/lien holder information you would like updated.
Enter the following information for all drivers that need to be added to this Automobile quote.
Enter the following information for all drivers that need to be added to this Automobile quote.
Name
License Number
License State
Date of Birth
Please describe the update you would like made to the coverage limits.
Please describe the update you would like made to the coverage limits.
Please enter the updates your would like made to the Comprehensive deductibles for this Automobile quote.
Please enter the updates your would like made to the Comprehensive deductibles for this Automobile quote.
Please enter the updates your would like made to the Collision deductibles for this Automobile quote.
Please enter the updates your would like made to the Collision deductibles for this Automobile quote.
Please select the optional coverages you would like added to this Automobile quote.
Please enter the updates your would like made to the Collision deductibles for this Automobile quote.
OEM Parts
Agreed Value
Rental Reimbursement
Towing
Vehicle Customization
Other
Please enter the optional coverages you would like added to this Automobile quote.
Please enter the optional coverages you would like added to this Automobile quote.
Please select the credits / discounts you would like added to this Automobile quote.
Please select the credits / discounts you would like added to this Automobile quote.
Student away at school over 100 miles without a car
Good student (B or better GPA)
Low mileage
Driver training (Certificate available)
Please enter the driver away at school and the car they primarily drive.
Please enter the driver away at school and the car they primarily drive.
Student Name
Vehicle
Please provide the student's name who will receive the Good Student discount.
Please provide the name of the student(s) who will receive the Good Student discount.
Student Name
Which vehicle(s) should receive the low mileage discount?
Which vehicle(s) should receive the low mileage discount?
Vehicle Description
Please provide the name(s) of the driver(s) who took driver training.
Please provide the name(s) of the driver(s) who took driver training.
Driver Name
Billing Options
What is the customer's preferred payment method?
What is the customer's preferred payment method?
Check
Credit Card
EFT
What is the customer's preferred billing frequency?
What is the customer's preferred billing frequency?
Monthly
Quarterly
Semi-Annual
Pay in Full
What is the customer's preferred payment plan?
What is the customer's preferred payment plan?
Down payment with 11 equal monthly payments
12 equal monthly payments
Please type any special issuance instructions below.
Please type any special issuance instructions below.
Kurt Thoennessen, CAPI
(203) 405-2645
http://ajg.com/
kurt_thoennessen@ajg.com
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