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Types of Insurance*

Home

Renters

Auto

Motorcycle

Life

Boat

Umbrella

Name*

First Last

Email*

Mobile Phone*

Can we text you?*

Yes

Home/Work Phone

Current Address

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Physical Address*

Same as Mailing Address

Street Address Address Line 2 City State ZIP Code

Primary Applicant

Date of Birth*

Month

Day

Year

Gender*

Marital Status

Drivers License Number

Drivers License State

Motorcycle Endorsement?

Yes

Occupation

Education Level

Is there a Co-Applicant?*

Is there anyone else on the vehicle title(s)?

Yes

Co-Applicant

Co-Insured Name*

First Last

Co-Insured Date of Birth*

Month

Day

Year

Co-Insured Gender*

Co-Insured Relationship to Primary Insured*

Co-Insured Drivers License Number

Co-Insured Drivers License State

Co-Insured Motorcycle Endorsement?

Yes

Co-Insured Email

Co-Insured Phone

Co-Insured Occupation

Co-Insured Education Level

Property Information

Property Address*

Same as Mailing Address

Street Address Address Line 2 City State ZIP Code

Do you currently Home Insurance?*

What is the reason you do not have Home insurance?*

What is the name of your current home Insurance carrier?*

Type of Home

Primary Use For Home

Are there multiple dwellings on this property?

Yes

Roof Update Year

Security System

Is this a New Purchase?

Yes

Purchase Date

MM slash DD slash YYYY

Purchase Price

Additional Property Coverage Interests

None

Flood

Hurricane

Earthquake

Have Dogs?

Yes

Breed(s) of Dog(s)

Is home newly built?

Yes

Have you had any claims in the past five (5) years?

Yes

Please describe the claim(s) and estimated date of loss*

Home Information

Home Currently Under Construction?*

Yes

Year Built

Square Feet

# of Bedrooms

# of Bathrooms

# of Stories

Construction Type

Roof Type

Foundation Type

Garage Type

Garage Number of Vehicles

Has Wood Burning Stove?*

Yes

Has Fireplace?*

Do you currently have Auto Insurance?*

What is the name of your current Auto Insurance carrier?*

What is the reason you do not have Auto insurance?*

Has any driver had any tickets or claims in the last five (5) years?*

Yes

Please describe the ticket(s) and/or claim(s)*

Additional Household Members

Are there other licensed drivers in your household?*

Examples: Parent, Grandparent, Sibling, Relative, Unrelated Person.

Yes

Do they have their own vehicle and current insurance?*

Yes

This field is hidden when viewing the form

What is the relationship of the additional household members?

Parent / Grandparent

Child

Sibling

Relative

Unrelated

Vehicles

Number of Vehicles*

Vehicle 1

1. VIN

1. Year*

1. Make*

1. Model*

1. Annual Miles Driven

1. Primary Use

1. Ownership

Own

Lease

1. Lienholder?*

Yes

1. Name of Lienholder*

1. Is vehicle used for Ridesharing or Food Deliveries*

Yes - Uber / Lyft / etc.

Yes - UberEats / Doordash / etc.

1. Is vehicle rented out on Turo?

Yes

Vehicle 2

2. VIN

2. Year*

2. Make*

2. Model*

2. Annual Miles Driven

2. Primary Use

2. Ownership

Own

Lease

2. Lienholder?*

Yes

2. Name of Lienholder*

2. Is vehicle used for Ridesharing or Food Deliveries*

Yes - Uber / Lyft / etc.

Yes - UberEats / Doordash / etc.

2. Is vehicle rented out on Turo?

Yes

Vehicle 3

3. VIN

3. Year*

3. Make*

3. Model*

3. Annual Miles Driven

3. Primary Use

3. Ownership

Own

Lease

3. Lienholder?*

Yes

3. Name of Lienholder*

3. Is vehicle used for Ridesharing or Food Deliveries*

Yes - Uber / Lyft / etc.

Yes - UberEats / Doordash / etc.

3. Is vehicle rented out on Turo?

Yes

Vehicle 4

4. VIN

4. Year*

4. Make*

4. Model*

4. Annual Miles Driven

4. Primary Use

4. Ownership

Own

Lease

4. Lienholder?*

Yes

4. Name of Lienholder*

4. Is vehicle used for Ridesharing or Food Deliveries*

Yes - Uber / Lyft / etc.

Yes - UberEats / Doordash / etc.

4. Is vehicle rented out on Turo?

Yes

Vehicle 5

5. VIN

5. Year*

5. Make*

5. Model*

5. Annual Miles Driven

5. Primary Use

5. Ownership

Own

Lease

5. Lienholder?*

Yes

5. Name of Lienholder*

5. Is vehicle used for Ridesharing or Food Deliveries*

Yes - Uber / Lyft / etc.

Yes - UberEats / Doordash / etc.

5. Is vehicle rented out on Turo?

Yes

Vehicle 6

6. VIN

6. Year*

6. Make*

6. Model*

6. Annual Miles Driven

6. Primary Use

6. Ownership

Own

Lease

6. Lienholder?*

Yes

6. Name of Lienholder*

6. Is vehicle used for Ridesharing or Food Deliveries*

Yes - Uber / Lyft / etc.

Yes - UberEats / Doordash / etc.

6. Is vehicle rented out on Turo?

Yes

Special Motorcycle Coverages

Enhanced Injury Protection

Yes

Physical Damage

Actual Cash Value

None - Liability Only

Roadside Assistance

None

Roadside

Roadside w/ Trip Interruption

Carried Contents

None

$1,000

$2,000

$3,000

Accessories Coverage

Safety & Riding Apparel

Transport Trailer Coverage?

Yes

Trailer Value

Boat Information

Serial Number*

Year*

Make*

Model*

Hull ID Number

Boat Registration Number

This is the ID number assigned to your boat by the state.

Hull Material

Number of Motors

Propulsion Type

Max Horsepower

Max Speed

Current Value

Fishing Equipment Coverage

Insure the Trailer?

Yes

Umbrella Coverage Information

Number of Properties

Number of Vehicles

Number of Drivers

Any drivers under age 25?

Yes

Any drivers over age 75?

Yes

Liability Limit

Life Insurance

Primary Applicant: Amount of Coverage*

Primary Applicant: Duration*

Does Primary Applicant Have a Current Life Policy?

Yes

Does Primary Applicant Use Nicotine?

Yes

Primary Applicant: Height

Feet and Inches

Primary Applicant: Weight

Pounds (lbs)

Does Co-Insured Want Life Insurance?

Yes

Co-Insured: Amount of Coverage*

Co-Insured: Duration*

Does Co-Insured Have a Current Life Policy?

Yes

Does Co-Insured Use Nicotine?

Yes

Co-Insured: Height

Feet and Inches

Co-Insured: Weight

Pounds (lbs)

Life Insurance - Primary Beneficiary

Should Co-Applicant Be Primary Beneficiary?

Yes

Primary Beneficiary Name

Beneficiary Date of Birth

Month

Day

Year

Beneficiary Relationship to Insured

Percent of Benefits to Receive

Please enter a number from 0 to 100.

Is there a Contingent Beneficiary?

Yes

Contingent Beneficiary Name

Contingent Beneficiary Date of Birth

Month

Day

Year

Contingent Beneficiary Relationship to Insured

Percent of Benefits to Receive

Please enter a number from 0 to 100.

Wrapping Up

When do you want your policies to start?

MM slash DD slash YYYY

Additional Comments

Attach Documents, Images, or Other Files

Drop files here or

Max. file size: 12 MB.

Would you like a quote from a specific agent?

How were you referred to us?

Would you like to create a user account?

Yes

Username*

Only letters and numbers.

Password*

Enter Password Confirm Password

Consent*

Like most insurance agencies, we use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.

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Name

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Current Address

Primary Applicant

Co-Applicant

Property Information

Home Information

Additional Drivers

Driver 1 Information

Driver 2 Information

Driver 3 Information

Driver 4 Information

Driver Tickets or Claims

Additional Household Members

Vehicles

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

Special Motorcycle Coverages

Boat Information

Umbrella Coverage Information

Life Insurance

Life Insurance - Primary Beneficiary

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Billy Davis Insurance Group

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Current Address

Primary Applicant

Co-Applicant

Property Information

Home Information

Additional Drivers

Driver 1 Information

Driver 2 Information

Driver 3 Information

Driver 4 Information

Driver Tickets or Claims

Additional Household Members

Vehicles

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

Special Motorcycle Coverages

Boat Information

Umbrella Coverage Information

Life Insurance

Life Insurance - Primary Beneficiary

Wrapping Up

Billy Davis Insurance Group

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For Clients

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