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Check All Types of Property You Need Covered
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Commercial Auto
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Vehicle #1
Year
Make
Model
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What Type of Coverage? (Vehicle #1)
Full Coverage
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Vehicle #2
Year
Make
Model
Vin #
What Type of Coverage? (Vehicle #2)
Full Coverage
Liability Only
Vehicle #3
Year
Make
Model
Vin #
What Type of Coverage? (Vehicle #3)
Full Coverage
Liability Only
Do You Transport Anyone Other Than Your Centers Children?
No
Yes
Do You Provide Transportation To/From School/Field Trips?
No
Yes
Do You Allow Drivers Under 21 to Transport Children?
No
Yes
How Many Drivers Shall Be Listed?
One
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Three
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Five
Six
Driver #1
Name
Date of Birth
Drivers License Number
Driver #2
Name
Date of Birth
Drivers License Number
Driver #3
Name
Date of Birth
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Driver #4
Name
Date of Birth
Drivers License Number
Driver #5
Name
Date of Birth
Drivers License Number
Driver #6
Name
Date of Birth
Drivers License Number
Workers Compensation
How Many Employees Do You Have At One Time?
Provide Annual Payroll for All Employees
Miscellaneous Details
Have There Been Any Claims in the Last 5 Years?
No
Yes
Is This a New Venture?
No
Yes
What Insurance Company are You Currently With?
What Is Your Current Annual Premium?
How Did You Hear About Blackwell Insurance Agency?
Please Provide The Date Your Quote Is Needed By If Applicable
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Permission to text?
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Additional Driver Info
Provide full name, Birthdate, Driver's License Number, and Employment information of EACH driver
Home Insurance Information
Is this a new purchase?
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New Property Address
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Street Address
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Year Built
*
Year Purchased
Approx. Value of Home
Style of Home
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Total Square Feet of Home
Only count above grade square footage. Do not include basement.
Is there a Basement?
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Percent of Basement that is finished
Do you have any dogs?
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List Breeds
Do you have a trampoline?
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Is the Trampoline:
In a fully fenced/gated back yard
Burried in the ground
Has safety net
In an open backyard with no fence
List any items you need to schedule (jewelry, collections, guns, etc)
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Auto Insurance Informaiton
How many vehicles?
*
How many vehicles?
1
2
3
4+
Vehicle 1
Vehicle 1 - Year, Make and Model
*
Vehicle 1 - VIN
Vehicle 1 - Primary Driver
*
Vehicle 1 - Liability Limits
*
100/300
250/500
50/100
25/65
Not sure
Vehicle 1 - Comp Deductible
*
None
$100
$250
$500
$1,000
Vehicle 1 - Collision Deductible
*
None
$100
$250
$500
$1,000
Roadside Service
*
Yes
No
Rental Car Coverage
*
Yes
No
Do you have a loan or lease on this vehicle?
*
Yes
No
Loan or Lease Company
*
Vehicle 2
Vehicle 2 - Year, Make and Model
*
Vehicle 2 - VIN
Vehicle 2 - Primary Driver
*
Vehicle 1 - Liability Limits
*
100/300
250/500
50/100
25/65
Not sure
Vehicle 2 - Comp Deductible
*
None
$100
$250
$500
$1,000
Vehicle 2 - Collision Deductible
*
None
$100
$250
$500
$1,000
Roadside Service
*
Yes
No
Rental Car Coverage
*
Yes
No
Do you have a loan or lease on this vehicle?
*
Yes
No
Loan or Lease Company
*
Vehicle 3
Vehicle 3 - Year, Make and Model
*
Vehicle 3 - VIN
Vehicle 3 - Primary Driver
*
Vehicle 3 - Liability Limits
*
100/300
250/500
50/100
25/65
Not sure
Vehicle 3 - Comp Deductible
*
None
$100
$250
$500
$1,000
Vehicle 3 - Collision Deductible
*
None
$100
$250
$500
$1,000
Roadside Service
*
Yes
No
Rental Car Coverage
*
Yes
No
Do you have a loan or lease on this vehicle?
*
Yes
No
Loan or Lease Company
*
Vehicle 4
Vehicle 4 - Year, Make and Model
*
Vehicle 4 - VIN
Vehicle 4 - Primary Driver
*
Vehicle 4 - Liability Limits
*
100/300
250/500
50/100
25/65
Not sure
Vehicle 4 - Comp Deductible
*
None
$100
$250
$500
$1,000
Vehicle 4 - Collision Deductible
*
None
$100
$250
$500
$1,000
Roadside Service
*
Yes
No
Rental Car Coverage
*
Yes
No
Do you have a loan or lease on this vehicle?
*
Yes
No
Loan or Lease Company
*
Upload Auto Insurance paperwork
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Contact Us
Blackwell Insurance Agency
23002 Lake Center Dr #200
Lake Forest, CA 92630
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949-421-0222
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