Quoting Sheet

Required General Information

Name * First Last

Referred By:
Please let us know who referred you...we send referral gifts! First Last

Gender *

Male Female

Street Address *

City

Zip Code
*

Email

Occupation/Degree Earned
(Needed for Affinity Discount Purposes)

Please list the FULL NAMES, BIRTH DATES, and OCCUPATION/DEGREE EARNED for any additional household members.

Auto Quote Information

Please complete the following information if you are interested in receiving an auto quote. REMEMBER: Auto and Home policies cross discount one another!! The more information you are able to provide will help us produce a more accurate quote.

Vehicle 1 Year-Make-Model

VIN- we can produce a quote without the VIN. Providing it will validate the quote for any additional car features.

Vehicle Usage

Pleasure Commuter

Annual Miles

Approximate Odometer Reading

Approximate Purchase Date

Vehicle 2 Year-Make-Model

VIN-we can produce a quote without the VIN. Providing it will validate the quote for any additional car features.

Vehicle Usage

Pleasure Commuter

Annual Miles

Approximate Odometer Reading

Approximate Purchase Date

Please list the above information for any additional vehicles to be quoted.

Do any rated drivers have tickets of violations in the past three years? Of so, please list the driver, type of violation and the approximate date cited or convicted

Home Quote Information

Please fill in the below information to receive a home quote. Auto and Home policies cross discount one another. The more information you are able to provide will help us produce a more accurate quote.

Property Type

I am not interested in a home quote at this time Home Owners- Primary Residence Renters Secondary or Seasonal Home Landlord Protector- Home Rented to Others Condo Condo Rented to Others Other

Property Address (if different than the one already listed)

Year Built

Square Feet

Stories

1 2 3 Other

Construction Type

Wood Frame Stucco Wood Siding Wood Shakes Concrete/Masonry Other

Fire Sprinklers

No Yes, Fully Sprinkled Yes, Partially Sprinkled

Smoke Dectectors

No Yes

Fire Alarm

No Yes, Local Alarm (sounds at property only) Yes, Central Alarm (connects to a station)

Burglar Alarm

No Yes, Local Alarm (sounds at property only) Yes, Central Alarm (connects to a station)

Swimming Pool

No Yes

Basement

No Yes

Approximate Year Roof was Last Replaced

Roof Type

Asphalt Shingle Rock and Tar Metal Concrete Fiber Tile Other

Garage Type (applies to homeowners only)

No Garage 1 Car Attached 2 Car Attached Detached Garage Other

Automatic Gas Shut Off Valve

Yes No I don't know

The above information will allow us to generate a preliminary quote. Please use the space below to make any necessary home comments.

Life Quote

Please provide the following information. Again, a life policy will further discount auto and home policies!

Amount of Insurance

I am not interested in a Life quote at this time $75,000 $150,000 $250,000 $500,000 $1,000,000 Other

Length of Policy

Whole Life 10 Year Term 20 Year Term 30 Year Term Other

Umbrella Quote

An umbrella policy is additional liability coverage on top of your auto and home policies. For example, if you have $500,000 Bodily Injury Liability coverage on your auto policy and a $1,000,000 umbrella, you have $1,500,000 of total liability coverage.

Umbrella Coverage

I am not interested in an umbrella quote at this time $1,000,000 $2,000,000 $3,000,000 Other

PLEASE SUBMIT TO COMPLETE THIS FORM. We will send you a quote within 2 business days.

Please call or e-mail with any questions.
415.800.3469
quote@chigosagency.com

Wufoo

Required General Information

Auto Quote Information

Home Quote Information

Life Quote

Umbrella Quote

PLEASE SUBMIT TO COMPLETE THIS FORM. We will send you a quote within 2 business days.