Personal Lines Intake Personal Lines Insurance Request Step 1 of 22 - Type of insurance quote 4% Name(Required) First Last Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Marital Status(Required) Single Married Divorced Widowed OccupationYour line of work may qualify you for additional discounts. Thank you to all our First Responders, Military members and family, and Educators!What type of insurance can we quote for you?(Required) Auto Home Condo Umbrella Investment Property Motorcycle/Slingshot/ATV Golf Cart Boat RV Drivers License Is this for a purchase or currently owned property?(Required) New Purchase Already Own How do you use the property?(Required) Primary Residence Secondary Residence Long-term Rental (6-months or longer) Short-term Rental (6-mos or less) Current Address (No PO Boxes)(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address of Property Being Purchased(Required) Same as current address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have insurance currently in-force for the lines of business you are requesting quotes?(Required) Yes No This field is hidden when viewing the formSection BreakName of Current Insurance Provider(Required)Please list the name of the CARRIER and NOT not the name of the agentHow long have you had that policy?(Required)Less than a yearMore than a year but less than 3 yearsMore than 3 years but less than 5 yearsMore than 5 yearsWhen does your current policy expire?(Required) MM slash DD slash YYYY Other than price, what is most important to you when it comes to your insurance needs?(Required)Check all that apply Self-service options Personal Service & Attention Claims Experience Local agent Other Select All Purchase date(Required)Please list either the date you purchased the property or your estimated closing date. MM slash DD slash YYYY Is the property older than 15 years?(Required) Yes No Uknown Any short-term rental usage at this property?(Required)If you use a service like AirBnB/VRBO or other service to rent out a room, whole-house or other structure on the property, please answer YES. Yes No Swimming Pool(Required) Yes No Monitored Burglar & Fire Alarm?(Required) Yes No Solar Panels(Required) Yes No Dog(s)?(Required) Yes No How Many Solar Panels? Add RemoveDog BreedsIf mixed please indicate type of mix. Add RemoveHave you had any home or renter's insurance claims in the past 5 years?(Required) Yes No Roof Material(Required)3-tab ShinglesArchitectural ShinglesMetalTile/ClayYear Roof Updated(Required)Please list the most recent the year the roof was updated in order to qualify for the best rate possible. If original or unknown, please enter the year built.Electrical Type(Required)CopperAluminumFusesKnob & TubeUnknownYear Electrical UpdatedPlease list the most recent the year the electrical was updated in order to qualify for the best rate possible. If original or unknown, please enter the year built.Plumbing Type(Required)CopperPVC/PEXIron/Galvanized PipingUnknownYear Plumbing UpdatedPlease list the most recent the year the plumbing was updated in order to qualify for the best rate possible. If original or unknown, please enter the year built.Year HVAC UpdatedPlease list the most recent the year the HVAC was updated in order to qualify for the best rate possible. If original or unknown, please enter the year built.Want coverage for any high valued items?(Required) Artwork Collectibles Firearms Jewelry None Other Valuable Items List (Click the + to add additional items)Please list each item and include an appraised/estimated value. Only one item per row please. Add RemovePlease provide any additional information you feel might help us in finding a competitive insurance option for you Total Drivers in Home(Required) 1 2 3 4 5 Total Vehicles in Home(Required) 1 2 3 4 5 Vehicle Year / Make / Model(Required)VINBusiness Use(Required) Yes No Carshare, Rideshare or Delivery?(Required)Is this vehicle is used for any Carshare (like TURO), Rideshare (like Uber/Lyft) or Food Delivery (like Favor/DoorDash) service? Yes No Approximate Annual Miles(Required)How many miles would you estimate you driver this vehicle on an annual basis?Coverage Type(Required)Liability ONLYLiability + Physical Damage (Comprehensive & Collision Coverage)Liability ONLY How long have you owned this vehicle?(Required)Just purchasedLess than a yearMore than a year but less than 3 yearsMore than 3 years but less than 5 yearsMore than 5 years Driver 2 InfoName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Drivers LicenseRelationship to you(Required) Spouse/Partner Child Parent Other Vehicle used by Driver #2Vehicle Year / Make / Model(Required)VINBusiness Use(Required) Yes No Carshare, Rideshare or Delivery?(Required)Is this vehicle is used for any Carshare (like TURO), Rideshare (like Uber/Lyft) or Food Delivery (like Favor/DoorDash) service? Yes No Approximate Annual Miles(Required)How many miles would you estimate you driver this vehicle on an annual basis?Coverage Type(Required)Liability ONLYLiability + Physical Damage (Comprehensive & Collision Coverage)Liability ONLY How long have you owned this vehicle?(Required)Just purchasedLess than a yearMore than a year but less than 3 yearsMore than 3 years but less than 5 yearsMore than 5 years Driver #3Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Drivers LicenseRelationship to you(Required) Child Parent Other Vehicle used by Driver #3Vehicle Year / Make / Model(Required)VINBusiness Use(Required) Yes No Carshare, Rideshare or Delivery?(Required)Is this vehicle is used for any Carshare (like TURO), Rideshare (like Uber/Lyft) or Food Delivery (like Favor/DoorDash) service? Yes No Approximate Annual Miles(Required)How many miles would you estimate you driver this vehicle on an annual basis?Coverage Type(Required)Liability ONLYLiability + Physical Damage (Comprehensive & Collision Coverage)Liability ONLY How long have you owned this vehicle?(Required)Just purchasedLess than a yearMore than a year but less than 3 yearsMore than 3 years but less than 5 yearsMore than 5 years Driver #4Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Drivers LicenseRelationship to you(Required) Child Parent Other Vehicle used by Driver #4Vehicle Year / Make / Model(Required)VINBusiness Use(Required) Yes No Carshare, Rideshare or Delivery?(Required)Is this vehicle is used for any Carshare (like TURO), Rideshare (like Uber/Lyft) or Food Delivery (like Favor/DoorDash) service? Yes No Approximate Annual Miles(Required)How many miles would you estimate you driver this vehicle on an annual basis?Coverage Type(Required)Liability ONLYLiability + Physical Damage (Comprehensive & Collision Coverage)Liability ONLY How long have you owned this vehicle?(Required)Just purchasedLess than a yearMore than a year but less than 3 yearsMore than 3 years but less than 5 yearsMore than 5 years Driver #5Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Drivers LicenseRelationship to you(Required) Child Parent Other Vehicle used by Driver #5Vehicle Year / Make / Model(Required)VINBusiness Use(Required) Yes No Carshare, Rideshare or Delivery?(Required)Is this vehicle is used for any Carshare (like TURO), Rideshare (like Uber/Lyft) or Food Delivery (like Favor/DoorDash) service? Yes No Approximate Annual Miles(Required)How many miles would you estimate you driver this vehicle on an annual basis?Coverage Type(Required)Liability ONLYLiability + Physical Damage (Comprehensive & Collision Coverage)Liability ONLY How long have you owned this vehicle?(Required)Just purchasedLess than a yearMore than a year but less than 3 yearsMore than 3 years but less than 5 yearsMore than 5 years Investment PropertyAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Property Status(Required) Currently Occupied with Tenants Listed For Sale - No Occupants Listed For Rent - No Occupants Undergoing Renovations - Vacant Motorcycle/Slingshot/ATVName of Primary Driver(Required) First Last Vehicle Type(Required) Motorcycle Slingshot ATV Is Vehicle Used for Racing?(Required) Yes No Current Motorcycle License(Required) Yes No Has Driver Completed Safety Course?(Required) Yes No Year(Required)Make(Required)Model(Required)VIN UmbrellaIn order to purchase an umbrella liability policy you must have auto liability limits of at least $250,000/$500,000/$250,000 and home/renters liability of at least $300,000.(Required) I understand that if the current liability limits on my auto and home/renters policies do not meet those minimums I will not be eligible to purchase an umbrella liability policy. How many homes do you own?(Required)This includes primary, secondary, vacation, rental and investment properties.How many home/renters claims have you made in the last 5 years?(Required)How many vehicles do you own?(Required)How many auto claims have you made in the last 5 years?(Required)Any drivers on your auto policy have an at-fault accident in the last 5 years?(Required) Yes No Do you own any of the following items?(Required) Boat/Yacht Motorcycle ATV Golf Cart Vacant Land Business Boat InformationWhere is boat stored?(Required) Primary Residence Marina - Slip Marina - Dry Stack Other Year(Required)Make(Required)Model(Required)Hull NumberMotor Type(Required) Inboard Outboard Top Speed (MPH)(Required)Boat Length(Required)Boat is used for racing?(Required) Yes No Do you own a boat trailer?(Required) Yes No Golf CartYearMakeModelPrimary Use(Required) Transportation Golfing Fuel Type(Required) Electric Gas Recreational VehicleRV Type(Required) Bumper Pull 5th Wheel Motorcoach Other Year(Required)Make(Required)Model(Required)VINLength How did you first hear about Leal Insurance Services?(Required) Google Search Current Client Referral Channel Partner Referral (Other Agent, Realtor, Lender) Social Media (Facebook, Instagram, Twitter, LinkedIn) Local Event Other Acknowledge & Consent(Required) I consent & agree to the following:By submitting this request you are authorizing 217 Insurance Services, LLC, its affiliates and carrier partners the access to pull the necessary reports (i.e. claims, credit and loss history) to confirm the data submitted. Submitting your quote request does not constitute a binding confirmation of a new or revised insurance coverage. 217 Insurance Services, LLC is committed to respecting your privacy and communication preferences. So that we may remain compliant with state and federal regulations, we need your expressed permission to communicate with you through phone, text and email as needed. You may opt-out of all future communication at any time by making your preferences known to us.CAPTCHA
