Insurance Quotes in Lake Ozark MO | Rock Island Insurance

Personal Fast App

A survey form to collect information of the new leads

Named Insured First & Last Name (You)(Required)

Email Address(Required)

Phone(Required)

Birthdate(Required)

Gender(Required)

Marital Status(Required)

Are you working with an agent?(Required)

Yes

Name of Agent you are working with?(Required)

Are you currently employed?(Required)

Occupation/Job Title(Required)

Employer(Required)

School Name(Required)

Street Address(Required)

Address Line 2

City(Required)

State(Required)

Zip Code(Required)

Secondary Name Insured

Spouse/Significant Other(Required)

Gender(Required)

DOB(Required)

Phone(Required)

Email(Required)

Select One(Required)

Occupation(Required)

Employer(Required)

School Name(Required)

Name of Business(Required)

Policies

Click all that apply(Required)

Policy Start Date(Required)

How did you find us?(Required)

Who shall we thank for referring you?(Required)

Home Details - 60% Complete

Is this new construction?(Required)

Yes

Estimated Closing Date(Required)

Property usage(Required)

Property type(Required)

Percentage of time at this home(Required)

Unoccupied for more than 30 days in a row?(Required)

Yes

Will you rent this home?(Required)

Yes

Shortest rental duration allowed(Required)

Lease duration(Required)

Long term (6+ mo.)

Short term (less than 6 mo.)

Home address (to be insured)(Required)

City(Required)

State(Required)

Zip Code(Required)

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HomeDetails70Complete

Year Built(Required)

Square Feet(Required)

Garage(Required)

Bathrooms(Required)

# of Stories(Required)

Exterior Construction(Required)

Fireplace(Required)

Foundation(Required)

Roof(Required)

Age of Roof(Required)

Pool/Hot Tub(Required)

Does the pool have a slide?(Required)

Yes

Does the pool have a diving board?(Required)

Yes

Is it located in a fenced yard?(Required)

Yes

Trampoline(Required)

Yes

Does the trampoline include safety netting?(Required)

Yes

Discount questions (click all that apply)(Required)

Dogs(Required)

Yes

Breed of dog(s)(Required)

Home updates (check all that apply)

Electrical

HVAC

Plumbing

All must be updated in past 25 years

Electrical - Year updated(Required)

HVAC - Year updated(Required)

Plumbing - Year updated(Required)

Current Insurance Provider

Current Premium

2nd Home Details

Address to be insured(Required)

City(Required)

State(Required)

Zip Code(Required)

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2nd Home Details

Bathrooms(Required)

Age of Roof(Required)

Pool/Hot tub(Required)

Trampoline(Required)

Yes

Does the trampoline include safety netting?(Required)

Yes

Is it located in a fenced yard?(Required)

Yes

Does the pool have a slide?(Required)

Yes

Does the pool have a diving board?(Required)

Yes

Home updates (check all that apply)

Electrical

HVAC

Plumbing

All must be updated in past 25 years

Electrical - Year updated(Required)

HVAC - Year updated(Required)

Plumbing - Year updated(Required)

Discount questions (click all that apply)(Required)

Dogs(Required)

Yes

Breed of dog(s)(Required)

Current Insurance Provider

Current Premium

Condo Details

Is this new construction?(Required)

Yes

Estimated close date(Required)

Property Usage(Required)

Type of Condo(Required)

Building Style(Required)

Percentage of time at this home(Required)

Unoccupied for more than 30 days in a row(Required)

Yes

Lease duration(Required)

Long term (6+ mo.)

Short term (less than 6 mo.)

Condo address (to be insured)(Required)

Year Built(Required)

Square Feet(Required)

Garage(Required)

None

1 Car

2 Car

Bathrooms(Required)

# of Stories(Required)

Fireplace(Required)

Discount questions (click all that apply)(Required)

Have you had any prior claims in the last 5 years?(Required)

Yes

Prior claim details(Required)

Dogs(Required)

Yes

Breed of dog(s)(Required)

Current Insurance Provider

Current Premium

Renter Details

Property type(Required)

Exterior construction(Required)

Square feet(Required)

Dogs(Required)

Yes

Breed of dog(s)(Required)

Discount questions (click all that apply)(Required)

Fire Sprinklers

Gated Community

Monitored Alarm

None

Current Insurance Provider

Current Premium

Investment Property Details

Address

Is this a new construction?(Required)

Yes

Is this owned in the name of an entity?(Required)

Yes

Name of Entity (LLC, etc.)(Required)

EIN#(Required)

Current Insurance Provider

Current Premium

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Landlord Details (New Construction is YES)

Year Built(Required)

Square Feet(Required)

# of Stories(Required)

Foundation(Required)

Exterior construction(Required)

Roof(Required)

Age of Roof(Required)

Bathrooms(Required)

Garage(Required)

No. of Cars(Required)

Fireplace(Required)

Pool/Hot tub(Required)

Does the pool have a slide?(Required)

Yes

Is it located in a fenced yard?(Required)

Yes

Does the pool have a diving board?(Required)

Yes

Trampoline(Required)

Yes

Does the trampoline include safety netting?(Required)

Yes

Dogs(Required)

Yes

Breed of dog(s)(Required)

Discount questions (click all that apply)(Required)

This field is hidden when viewing the form

Landlord Details (New Construction is NO)

Bathrooms(Required)

Age of Roof(Required)

Pool/Hot tub(Required)

Trampoline(Required)

Yes

Is it located in a fenced yard(Required)

Yes

Does the pool have a slide(Required)

Yes

Does the pool have a diving board(Required)

Yes

Does the trampoline include safety netting(Required)

Yes

Home updates (check all that apply)(Required)

Electrical

HVAC

Plumbing

Electrical - Year updated(Required)

HVAC - Year updated(Required)

Plumbing - Year updated(Required)

Discount questions (click all that apply)(Required)

Dogs(Required)

Yes

Breed of dog(s)(Required)

Auto Details - 75% Complete!

Current Auto Insurance Company(Required)

Current Premium(Required)

Driver Details

Driver 1

First Name

Last Name

Gender

Date of Birth

Marital Status

Driver's License Number

Relationship

Occupation

Driver 1(Required)

Vehicle Details

Vehicle 1

Year

Make

Model

VIN

Ownership

Usage

Vehicle 1(Required)

Garaging address same as home on all vehicle(s)(Required)

Yes

Garaging address(Required)

Umbrella Details

Number of residences you occupy?(Required)

Number of rental units you own?(Required)

Number of drivers(Required)

Any driver under 25?(Required)

Yes

Number of autos you own?(Required)

Any boats, RVs, motorcycles, or other vehicles you own?(Required)

Yes

Life Insurance

Desired amount(Required)

Term length(Required)

Height(Required)

Weight(Required)

Current life insurance in force

Yes

Current life insurance amount(Required)

Current life insurance company(Required)

Do you or have you ever smoked tobacco?(Required)

Yes

Quantity(Required)

Frequency(Required)

Form(Required)

Last Used(Required)

Have you used marijuana in the last 5 years (Don't worry, you're still insurable)(Required)

Yes

Have you seen a doctor in the last 5 years?(Required)

Yes

Please indicate the approximate date and the reason for the visit(Required)

Have any immediate family members (parents and/or siblings) passed away prior to the age of 60 due to cancer, diabetes, or cardiovascular disease?(Required)

Yes

Any moving violations including but not limited to driving under the influence (DUI) under the last 5 years(Required)

Yes

Please provide details(Required)

Any private pilot activity in the last 3 years or planned for the future?(Required)

Yes

Any past travel in the last 2 years or future plans in the next 2 years to travel outside of the U.S.?(Required)

Yes

Please provide details including specific destination, frequency, and duration of travel(Required)

Are you a citizen or legal resident of the U.S.?(Required)

Yes

Boat Details

Driver name(Required)

Gender(Required)

Birthdate(Required)

Driver's license #(Required)

State Issued(Required)

Licensed at 16(Required)

Yes

Accident/Violation in the last 5 years(Required)

Yes

Original date licensed(Required)

Years of boating experience(Required)

Have you completed a safety course(Required)

Yes

Details of accident(s) and/or violation(s)(Required)

Current Insurance Provider

Current premium

Boat new or used (Required)

New

Used

Date purchased(Required)

Boat value(Required)

Boat year(Required)

Boat make(Required)

Boat model(Required)

Boat length(Required)

Propulsion type(Required)

Horse power(Required)

Maximum speed(Required)

Hull ID(Required)

Construction material(Required)

Fiberglass, Aluminum, Wood, etc...

Watercraft stored at home address(Required)

Yes

Leased/Rented to others(Required)

Yes

Watercraft storage location(Required)

Used for business(Required)

Yes

Previously salvaged(Required)

Yes

Permanent living quarters(Required)

Yes

High performance (Fast)(Required)

Yes

Number of motors(Required)

Exposed engine, other than outboard(Required)

Yes

Corporate owned(Required)

Yes

Name of owner(Required)

Do you have a lienholder(Required)

Yes

Lienholder(Required)

Any additional equipment(Required)

Protective devices(Required)

Do you have a trailer to insure(Required)

Yes

Trailer year(Required)

Trailer make(Required)

Trailer model(Required)

Trailer value(Required)

Trailer ID/Serial #(Required)

ATV/OHV/Golf Cart Details

Current Auto Insurance Company(Required)

Current Premium

Driver Details(Required)

Vehicle Details(Required)

RV/Travel Trailer Details

Driver Details(Required)

Vehicle Details(Required)

RV/Travel Trailer Details

Driver Name(Required)

Gender(Required)

Birthdate(Required)

Driver's license #(Required)

State Issued(Required)

Licensed at 16(Required)

Yes

Original date licensed(Required)

Year(Required)

Make(Required)

Model(Required)

Length (in ft)(Required)

How many slides

Year purchased

Estimated value today(Required)

VIN #(Required)

How many days per year is it used(Required)

RV rented commercially or used for business purposes(Required)

Yes

RV rented to others(Required)

Yes

RV taken to and from work or used at a work location(Required)

Yes

Primary vehicle use(Required)

Stored at home(Required)

Yes

Storage Address(Required)

Motorcycle Details

Current auto insurance company(Required)

Rider Details(Required)

Motorcycle Details

Year(Required)

Make(Required)

Model(Required)

VIN #(Required)

CC size(Required)

Trike(Required)

Yes

Stock(Required)

Yes

Garaging zip code(Required)

Vehicle use(Required)

Annual miles(Required)

Vehicle use details(Required)

Describe any modifications(Required)

Estimated current value(Required)

End Section

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