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What a have

Choose your coverage to get started *

PERSONAL AUTO
COMMERCIAL AUTO
RESIDENCIAL
RESIDENTIAL HOUSING
GENERAL LIABILITY
WORKERS COMPENSATION
AUTO DEALER
BOND

The full name and birthdate of the contract signer *

First

Last

Date of birth *

Name *

First

Last

Phone *

Email

Date of Birth *

Will the rental agreement contain the name or names of another person? *

Yes
No

Enter the full name, date of birth and contact email address of other people who will be included in the contract.

Name *

First

Last

Date of Birth *

Rental address *

Address Line 1

Address Line 2

City

State

Zip Code

Moving date

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is the above address the same as the property to be insured? *

Yes
No

Is the address above the same as your business address? *

Yes
No

Is this the same address as the garage for the car(s)? *

Yes
No

Address of the property to be insured *

Address Line 1

Address Line 2

City

State

Zip Code

Company address *

Address Line 1

Address Line 2

City

State

Zip Code

Garage address *

Address Line 1

Address Line 2

City

State

Zip Code

FEIN# or EIN# *

Company FEIN/EIN *

Name of your company *

A responsible individual. *

First

Last

Social Security Number *

The responsible person's driver's license photo *

Click or drag files to this area to upload. You can upload up to 10 files.

Are you a US citizen? *

Yes
No

Do you have a Green Card? *

Yes
No

Number of dealer plates *

Name and position for all persons with access to the cars

Name *

First

Last

Position *

Driver's license photos of all individuals with access to the vehicles *

Click or drag files to this area to upload. You can upload up to 50 files.

Are you planning to buy vehicles from outside of Florida? *

Yes
No

Total value of cars on the lot *

Average value of cars on the lot *

Will the dealer be enclosed by a fence? *

Yes
No

Will it have an alarm? *

Yes
No

Will the owner(s) and employees use the dealership's cars as their own? *

Yes
No

What is your occupation in the U.S.? *

Will all partners be included in the policy? *

Yes
No

Do any of the partners have an exemption? *

Yes
No

Do you have registered employees? *

Yes
No

How many employees? *

Annual payment amount *

Do you use subcontractors? *

Yes
No

Annual payment amount *

Do you currently have a workers' compensation policy, or have you ever had one? *

Yes
No

What is the annual gross revenue of the company? *

Owned or rented residence? *

Owned residence
Rented residence

Property paid off or financed? *

Paid-off property
Financed property

Are you married or in a domestic partnership? *

Yes
No

Does any other person aged 14 or older live at this address (even if they don’t drive)? *

Yes
No

Name *

First

Last

Date of Birth

Will the vehicle(s) be registered in your personal name or your company’s? *

Personal
Company

Property registered in personal or company name? *

Personal
Company

Use of the property *

Have any renovations been made to the property? *

Yes
No

What year? *

Has the property had its roof replaced or repaired? *

Yes
No

What year? *

Gated community? *

Yes
No

Is there a doorman or gate? *

Yes
No

Is there a fire alarm? *

Yes
No

Is it monitored? *

Yes
No

Is there a burglar alarm? *

Yes
No

Is it monitored? *

Yes
No

Is there a sprinkler system on the property? *

Yes
No

Does the house have a pool? *

Yes
No

Is it enclosed with a screen? *

Yes
No

Do you own any pets? *

Yes
No

Which one(s)? *

Yes
No

Does the property have an active policy? *

Yes, it has active insurance.
No, it's a new purchase.
No, it's uninsured.

Policy start date

Type of use of vehicle(s) *

Do you have an active policy? *

Yes
No

Do you have an active General Liability policy? *

Yes
No

Do you have an active Work Compensation policy? *

Yes
No

Do you have an active car policy (personal or commercial) for at least six months? *

Yes
No

Will the vehicle(s) be registered in your personal name or your company’s? *

Personal
Company

Is any vehicle financed? *

Yes
No

Driver’s license photo for every driver *

Click or drag files to this area to upload. You can upload up to 10 files.

Enter the vehicle's VIN(s) *

Any other information we should know that isn’t on this form?

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