Auto/Property New Client Form

Call Us: (480) 674 - 9248

Email Us: Rely@elysiumins.com

Auto/Property New Client Form

Auto/Property Quote Form*

Name*

First

Middle

Last

Date of Birth*

Address*

Phone*

Best Time of Day to Call?*

Email*

Automotive*

How Many Automobiles to Include in Policy?*

List your Vehicles Here*

Include Vehicle Years, Makes, Models, & Annual Mileage

How Many Drivers in Household?*

Drivers in Household*

Include Full Name, Date of Birth, Married/Single Status, Relationship to You, & Driver's License #

Do you use your vehicle(s) for business?*

Has any driver had their license suspended or revoked?*

In the Past Five Years

If Yes, Why?*

Explain who was involved, when, and why

Any accident or motor vehicle convictions in the past five years whether you or someone else was at fault?*

In the Past Five Years

If Yes, Why?*

Explain who was involved, when, and what happened in the accident

List all fire, theft, glass, and/or vandalism losses:*

In the Past Five Years

Who is your Present Insurance Coverage Through?*

Expiration Date?*

What is Your Annual Premium?*

What are Your Current Liability Limits?*

Property*

What Types of Property Are You Insuring?*

Home
Built-In Garage
Condominium or Co-op
Renters

What Year Was the Home Built, Style, & Number of Stories?*

What Month/Year was the Home Purchased?*

Is the Home a Primary or Secondary Residence?*

Primary
Secondary

How Many Months of the Year is it Occupied?*

How Many Mortgages?*

Roof Covering*

Asphalt Shingles
Tiles/Slate
Steel/Metal
Other

Primary Source of Heat*

Oil
Gas
Electric
Other

Alternative Source of Heat*

Wood/Coal/Pellet Stove
Space Heater
Other

How Close is the Nearest Fire Hydrant?*

How Close is the Nearest Fire Station?*

Protective Devices*

Smoke Detector
Fire Extinguisher
Dead Bolt Locks
Monitored Fire Alarm

Present Insurance Company?*

Policy Expiration Date?*

What is Your Current Amount of Coverage?*

Explain any Losses within the Last Five Years*

Are you interested in learning more about other types of insurance?*

*Form Fields Are Required!

Auto/Property New Client Form

Helpful Links

Contact

rely@elysiumins.com

Mon – Fri: 10 am – 8 pm

(480) 674 - 9248

Avondale, Arizona, USA