Request a Quote

Answering all of the questions as accurately as possible will ensure that proper discounts are applied to your quote.

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Insurance Quote Type ¬

Note: Clicking on more than one insurance type will activate the Bundled Options and display the additional fields needed to submit your request.

Applicant Information ¬

Contact Information ¬

How should we contact you during business hours?
(if via phone, you must enter the phone number(s) above)

Insurance Information ¬

Are you currently insured? Yes   No
If so, how long?
If so, name of current insurance company:
Residence Status:

Auto Insurance Information

Driver Information ¬

Driver Name Date of Birth
Gender Marital
(in the US)
in past 3 years
in past 3 years

Vehicle Information ¬

  Year Make Model Coverage # of Doors
Vehicle #1
Vehicle #2
Vehicle #3

Home/Condo Insurance Information

Home/Apt/Condo Information ¬

Street address of home/apt/condo to insure:
How long at this address?
If you have lived at the home/apt/condo you want to insure for less than 3 years, what was your prior address?

Current Insurance Information ¬

Do you currently have homeowners/condo/renters insurance? Yes   No
If so, Expiration Date?
If so, name of current auto insurance company:

Policy Details ¬

For how much do you want to insure your residence?
Desired Deductible:
When do you want this policy to begin?

Dwelling Information ¬

Type of Residence:
Type of Construction:
# Miles from Nearest Fire Department: Type of Wiring:
Within 1,000 Feet of Fire Hydrant: Yes   No Type of Heat:
If Townhouse, # of Units:   Not Applicable Type of Roof: Pitched   Flat

Upgrades (if applicable) ¬

Wiring:Yes   NoIf Yes, when:
Heating/AC:Yes   NoIf Yes, when:
Plumbing:Yes   NoIf Yes, when:
Roof:Yes   NoIf Yes, when:
Alarm System:Yes   No
Deadbolt Locks:Yes   No
Smoke Alarms:Yes   No
Sprinklers:Yes   No
Fire Extinguisher:Yes   No
Any Supplemental Heating: (fireplace, wood stove, etc.)Yes   No
Swimming Pool:Yes   No
Any Claims During Past 5 Years:Yes   No

Coverage Information ¬

If you have your policy readily available, please complete the following information. Otherwise, leave blank.

[Note: The standard homeowners/renters/condo policy provides certain amounts of coverage for valuable items (such as jewelry, furs, fine arts, silverware, musical instruments, guns, coins, stamps and collectibles). Please let Senate Select know if you want coverage for any of these items beyond the amount of automatic coverage provided.]

Motorycycle Insurance Information

Cycle Information ¬

Number of Cycles to Insure:
Turbo/Nitrous Kit? Yes   No Yes   No Yes   No Yes   No
Average Yearly Milage
Miles to Work (one way)
Anti-Lock Breaks? Yes   No Yes   No Yes   No Yes   No
Audible Alarm Device? Yes   No Yes   No Yes   No Yes   No
Liability Limits:
Selection to left applies to all cycles. Selection to left applies to all cycles. Selection to left applies to all cycles. Selection to left applies to all cycles.
(requires comprehensive)
Towing Yes   No Yes   No Yes   No Yes   No

Operator Information ¬

Number of Operators to Insure:
Full Name
Gender Male   Female Male   Female Male   Female Male   Female
Marital Status Married   Single Married   Single Married   Single Married   Single
Date of Birth
Do You Have a Motorcycle License? Yes   No Yes   No Yes   No Yes   No
How Many Years Have You Had a Motorcycle License?
License Status
Do You Have Proof of any "Safety Courses" Completed? Yes   No Yes   No Yes   No Yes   No
Active Member of any Motorcycle Associations? Yes   No Yes   No Yes   No Yes   No

Insurance Information ¬

Do you have motorcycle insurance currently? Yes   No Residence status:
During the Past Three Years: (Applies to both Auto and Motorcycle occurrences)
Do You Have Any At-Fault Accidents?
Do You Have Any Not-At-Fault Accidents?
Do You Have Any Comp Claims $1000.00?
Do You Have Any Minor Moving Violations?
Do You Have Any DWI⁄DUIs?
Do You Have Any Major Moving Violations?

Comments ¬

How did you hear about Senate Select Insurance?    (Please choose one option below)
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