Personal Quote Form

General Information

What type of coverage would you like us to quote?

AutoHomeUmbrella

First Name

Last Name

Physical Address

Mailing Address

Same as Physical Address

Mailing Address

Primary Phone Number

Primary Phone Type?

MobileHomeBusiness

May we contact you via text message?

YesNo

Gender

MaleFemale

Date of Birth

Marital Status

SingleMarriedDomestic PartnerWidowedSeparatedDivorced

Occupation

Some companies provide discounts based on your occupation. If you aren’t currently working, just put one of the following:

Student
Homemaker
Retired
Unemployed
Disabled

Which agent would you like to work with?

Where did you hear about us?

What date would you like your policies to start?

Advanced Quote Discount: Some companies provide discounts for quoting your insurance in advance of your renewal date. Setting the effective date of the quote 15 days in advance will automatically add these additional savings. If you need your policy to start before then, just choose the date that you need your coverage to start on.

Regardless of when you need your policy to start, we are going to get your quote to you as fast as possible!

Auto

Drivers

All licensed drivers in the household must be listed below, even if they’ve purchased auto insurance elsewhere. If a driver has purchased insurance coverage elsewhere, simply check the box below their name noting that they have coverage elsewhere.

Driver 1

First Name

Last Name

Gender

MaleFemale

Does this driver currently have auto insurance in force?

YesNo

Date of Birth

DL State

Driver's License Number

Marital Status

SingleMarriedDomestic PartnerWidowedSeparatedDivorced

Education

No High School DiplomaHigh School DiplomaSome College - No DegreeVocational/Technical DegreeAssociates DegreeBachelors DegreeMasters DegreePhDMedical DegreeLaw Degree

Occupation

Some companies provide discounts based on your occupation. If you aren’t currently working, just put one of the following:

Student
Homemaker
Retired
Unemployed
Disabled

Does this driver qualify for a Good Student Discount?

Good Student Discounts apply to full time students who maintain a B average or better

YesNo

Is this driver required to maintain a Certificate of Financial Responsibility (SR22)?

A Certificate of Financial Responsibility (SR22) is an endorsement required by the Department of Motor Vehicles (DMV) for certain violations such as an uninsured car accident or conviction of another traffic-related offense, such as a DUI.

YesNo

Add Driver

Remove Driver 1

Vehicles

Vehicle 1

Year

Make

Model

Vehicle Identification Number (VIN) VIN Decoder:

You can find your VIN in several different places:

Your current Auto Insurance ID Card
Your Vehicle Registration Card
Your current Auto Insurance Policies
Your vehicle’s driver’s side door jam or driver’s side dash (visible through the windshield from the outside of the vehicle).

Who is the primary driver of this vehicle?

Is this vehicle garaged at ?

YesNo

Vehicle Garage Address

Does this vehicle have a loan on it?

YesNo

Lienholder Name

Not required for a quote

Lienholder Address (Not required for a quote)

Would you like Loan/Lease Gap coverage on this vehicle?

Loan/Lease Gap coverage will pay the difference between the outstanding balance on your auto loan and the value of your vehicle in the event your vehicle is covered by a total loss.

Loan/Lease Gap coverage is only available for model year cars 2 years or newer.

YesNo

Would you like Collision coverage on this vehicle?

Collision insurance covers damage to your vehicle caused by colliding with another vehicle or an object (e.g., a telephone pole, a guard rail, a mailbox).

YesNo

Would you like Comprehensive coverage on this vehicle?

Comprehensive insurance covers non-collision related incidents like falling objects, fire, theft, flood, vandalism, wind, and more. In addition, it also covers contact with animals.

YesNo

Does your vehicle have any modifications or customizations?

Examples of popular modifications that drivers make to their vehicles include:

Custom paint job, murals, graphics or decals
Snow plow blades
Truck bed toppers
Electronic equipment like a custom stereo, PC, TV or video system
Custom tires, wheels or spinners
Custom spoilers, louvers, scoops or grilles
Speed enhancements like turbochargers, blowers and strokers
Anti-roll/anti-sway bars or winches
Added chrome
Accent/auxiliary lights
Suspension enhancers/hydraulics

YesNo

Please describe the modifications and provide an estimate of their value:

Examples of popular modifications that drivers make to their vehicles include:

Custom paint job, murals, graphics or decals
Snow plow blades
Truck bed toppers
Electronic equipment like a custom stereo, PC, TV or video system
Custom tires, wheels or spinners
Custom spoilers, louvers, scoops or grilles
Speed enhancements like turbochargers, blowers and strokers
Anti-roll/anti-sway bars or winches
Added chrome
Accent/auxiliary lights
Suspension enhancers/hydraulics

Is this vehicle titled to anyone other than the drivers listed above?

YesNo

Please provide the name of the entity or person who is listed as the title holder and the relationship this person and/or entity has with the driver.

Vehicle Use

PersonalFarmBusinessTo/From WorkTo/From School

For Personal, Farm, or Business, please enter the estimated annual mileage for this vehicle. For driving To/From Work or School please enter the distance in miles from home to work/school (one-direction):

Is this vehicle used for Rideshare/Transportation Network Company (TNC)?

The transportation (for compensation) of goods or people through Uber, DoorDash or other drive-for-hire services. Do not select Yes for general carpooling uses.

Note: Some Rideshare Programs (e.g. UberBlack and UberSUV) require driver partners to maintain commercial insurance policies, not private passenger auto; consult rideshare company guidelines.

YesNo

Add Vehicle

Remove Vehicle 1

Potential Discounts

Are members of your household any of the following?

Alumni Association Paid MemberAmerican Probation and Parole AssociationArchitectAttorneyBankers AssociationCertified and/or Licensed Professional EngineerChiropractorClassic Car Club MemberCollins Credit UnionCondo Unit OwnerCPACredit Union Employee AssociationEMS (Volunteer or Full Time)Fire Fighter (Volunteer or Paid)Funeral DirectorGovernment Employees & MilitaryHealth System EmployeeHomebuilders AssociationIllinois DentistIllinois EducatorInsurance or Financial Professionals with Professional DesignationsLaw Enforcement AssociationMaster TradespersonNational Association of Women Business OwnersNFL Alumni AssociationOptometric AssociationPharmacistPost Graduate Degree IndividualPrime Rewards PlusSelective Commercial Account EmployeeUnited States Military ServiceVeterinarianWest Bend GenerationWest Bend Mutual Insurance AgentWest Bend Mutual Insurance Co Associate

Do any drivers have a work vehicle?

In order to qualify for this discount, the work vehicle must be usually furnished to the driver.

YesNo

Desired Payment Frequency:

MonthlySemi-AnnuallyAnnually

Current Auto Coverage Information

Some companies give discounts based on your current insurance carrier and/or the limits of insurance you have.

Do you currently have auto insurance in force?

YesNo

Current Insurance Company:

Current Bodily Injury Limits

Some companies offer a single limit of bodily injury insurance coverage. This is called “Combined Single Limit” coverage. Instead of having 2 limits (1 limit “per person” and 1 limit “per accident”). If you currently have Combined Single Limit coverage, choose the drop down that most closely matches your limit based on the “per accident” coverage.

Less than $100,000 per person/$300,000 per accident$100,000 per person/$300,000 per accident$250,000 per person/$500,000 per accidentGreater than $250,000 per person/$500,000 per accident

Current Annual Premium:

Auto Notes:

Please let us know if there is any additional information that you feel we need to know about your Auto coverage.

Home

Is the Physical Address of your home different than ?

YesNo

Physical Address of Home

How many full years have you lived at this address?

Previous Address (if current less than 3 years)

What year was your home built?

If you are unsure, please provide your best guess.

Finished Living Area (Do not include finished basement, built-in garage area or lower level unfinished area in the finished living area):

If you are unsure, please provide your best guess.

Sq. Ft.

What style of home do you have?

1 Story/Ranch1 ½ Story2 StoryBi-LevelSplit Level/Tri-LevelDuplex (1 Side)Town House/Row House (Center)Town House/Row House (End)Mobile/Manufactured

What type of foundation does your home have?

When entering the type of foundation for your home, do not consider the garage space.

BasementCrawlspaceSlabMultiple Types

Foundation Types and Percentage of Each (Must equal 100%)

When entering the type of Foundation for your home, do not consider the garage space. If you have multiple foundation types, please enter the approximate percentage of each foundation type.

This is a freeform text box. Please add any other type(s) of foundations your home has along with the percentage of each.

Approximately what percentage of your basement is finished?

The area of a basement is considered finished when it’s similar to the upstairs living areas. It generally includes an electrical system, heat, finished floors, an accessible entrance/stairway, level ceilings, and finished walls. Most basements include a utility room that may contain a furnace, water heater, or other systems that service the house. These utility rooms are usually not considered to be finished space.

How much Water Backup of Sewer & Drain Coverage would you like?

Please use increments of $5,000. Any amount that is not an increment of $5,000 will be rounded up to the nearest $5,000. Minimum amount of coverage is $5,000.

Do you have a sump pump?

YesNo

Do you have a backup sump pump?

YesNo

What type of backup sump pump do you have?

BatteryWater DrivenSecondary sump pump powered by an automatic backup generator

What type of exterior walls do you have?

VinylWoodAluminumBrick on FrameSolid BrickStone on FrameMultiple Types

Exterior wall types and percentage of each (Must equal 100%)

This is a freeform text box. Please add any other type(s) of exterior wall material your home has along with the percentage of each.

Do you have an attached garage?

YesNo

How many cars fit in your attached garage?

How many full bathrooms does your home have? (shower or bathtub and toilet = 1 Full Bathroom)

0123456

How many half bathrooms does your home have? (shower only or toilet only = 1 Half Bathroom)

0123456

What type of roof do you have?

Asphalt ShinglesArchitectural ShinglesWood ShinglesSteel/MetalSlateMultiple Types

Roofing material and percentage of each (Must equal 100%):

This is a freeform text box. Please add any other type(s) of roofing material your home has along with the percentage of each.

What year was your roof last replaced?

If you are unsure, please provide your best guess.

What is your home's primary heating source?

Gas Furnace (Forced Air)Gas Furnace (Hot Water/Steam)Geothermal Heat PumpElectricOther

What is your home's primary heating source?

What year was your home's primary heating source last replaced?

If you are unsure, please provide your best guess.

Does your home have a secondary heating source (such as a wood burning stove)?

YesNo

Does your home have central air conditioning?

YesNo

Is your home’s primary electrical service protected by a Circuit Breaker Panel?

YesNo

What year was your home’s electrical service last updated?

If you are unsure, please provide your best guess.

Does your home have an automatic backup generator?

YesNo

What year was your home’s plumbing last updated?

If you are unsure, please provide your best guess.

Does your home have an attached deck?

YesNo

What type of deck do you have?

WoodComposite

What is the square footage of your deck?

If you are unsure, please provide your best guess.

Sq. Ft.

Does your home have a porch?

YesNo

What type of porch do you have?

OpenEnclosed (includes screened)

What is the square footage of your porch?

If you are unsure, please provide your best guess.

Sq. Ft.

Do you have any detached structures?

A detached structure is a building that is not connected to your home. Examples of detached structures include a garage, shed, or barn. Do not include detached decks, pools, fences, or other structures that are not buildings.

YesNo

Please describe each detached structure and give approximate dimensions (length & width) for each:

Do you have a pool?

YesNo

Is your pool above ground or in ground?

Above GroundIn Ground

Is there a fence surrounding access to the pool?

YesNo

Is access to the pool secured by a self-latching gate?

YesNo

Does the pool have an automatic cover?

YesNo

Does your pool have a diving board?

YesNo

Does your pool have a slide?

YesNo

Do you have a trampoline?

YesNo

Does your trampoline have a net?

YesNo

Do you own any dogs?

YesNo

Please select your dog breed(s) from the following list:

My Dog Breed is Not Listed BelowAkitaAmerican BulldogAmerican Pit Bull TerrierChowDingoDobermanGerman ShepherdGiant SchnauzerHuskiePresa CanarioRottweilerMalamuteMastiffStaffordshire Bull TerriorWolf Hybrid

Do any of your dogs have a history of biting?

YesNo

Please provide details about the biting incident(s):

Do you have any livestock? (e.g. chickens, cows, pigs, etc…)

YesNo

Please list what livestock you have with a head count for each:

Do you operate a business out of your home?

Insurance companies generally define a “business” as any activities where you earn more than $2,000 per year.

YesNo

Please describe your business and provide an estimate of your annual revenue:

Is your business currently insured on a separate Commercial General Liability policy?

YesNo

Do you wish to insure any business property?

A standard homeowners insurance policy limits the amount of coverage for business property to $2,500 at your home and $500 when away from your home.

YesNo

Do you have jewelry you wish to insure?

A standard homeowners insurance policy excludes coverage for mysterious disappearance of jewelry. Mysterious disappearance is insurance lingo for “loosing it”. Adding jewelry to a policy gives you coverage if you misplace your jewelry or if a stone falls out. In addition to not having coverage for mysterious disappearance, a standard homeowners policy limits the coverage for stolen jewelry to $1,500. Adding jewelry to a policy provides theft coverage for the amount you list it for.

YesNo

What is the total value of the jewelry you would like to insure?

Do you have firearms and/or related equipment you wish to insure?

A standard homeowners insurance policy limits the amount of coverage for theft of firearms and related equipment (ammunition for example) to $2,500. Adding firearms and related equipment to a policy provides theft coverage for the amount you list.

YesNo

What is the total value of firearms and related equipment you would like to insure?

Do you have a mortgage on your home?

YesNo

Mortgagee Name

Not required for a quote

Mortgagee Address (Not required for a quote)

Are your homeowner’s insurance premiums escrowed?

YesNo

Current Home Coverage Information

Do you currently have a homeowners insurance policy on this house?

YesNo

Current Carrier:

Current Annual Premium

Desired Payment Frequency:

MonthlySemi-AnnuallyAnnually

Home Notes:

Please let us know if there is any additional information that you feel we need to know about your Home coverage.

Umbrella

What umbrella limit are you requesting?

$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000$6,000,000$7,000,000$8,000,000$9,000,000$10,000,000

Why is a higher umbrella limit being requested?

Do you have other personal liability insurance (Auto, Motorcycle, Boat, Dwelling (Rentals), etc…) that either isn’t being quoted or isn’t currently insured through Compass Insurance at this time?

YesNo

Please provide details about coverages that are not being quoted/issued with Compass Insurance :

Umbrella Notes:

Please let us know if there is any additional information that you feel we need to know about your Umbrella coverage.

Final Step

General Notes:

Please let us know if there is any additional information that you feel we need to know.

I confirm that Compass Insurance has provided me with and I have reviewed the Credit Based Scoring Disclosure and Notice of Information Practices.

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