About Cole
Practice Areas
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About Cole
Practice Areas
News & Facts
Contact
Get a Quote
Request a Quote
Step 1 of 2
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Type of Insurance
Home
Renters
Auto
Life
Specialty Vehicles
Business
Special Event & Combative Sports - Accident Medical
Special Event & Combative Sports - General Liability
Name
*
First
Last
DBA
Effective Date
*
Date Format: MM slash DD slash YYYY
How did you hear about us?
*
Referral
Yellow Pages
Other
Let us know how you heard about us:
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Rent/own?
*
Rent
Own
How long?
*
Cell Number
Home Phone
Work Phone
Fax Number
Email Address
*
Enter Email
Confirm Email
Best Time to Contact
Anytime
Morning
Afternoon
Evening
Best Way to Contact
Email or Phone
Email
Phone
Type of Business
*
Duties
Date of Birth
*
Date Format: MM slash DD slash YYYY
Highest Level of Education
*
High School graduate
Some College
Associate's and/or Bachelor's degree
Master's degree
Doctoral or Professional degree
Occupation
Employer
Tickets/Claims/Accidents (Last 3 Years)
Prior Coverage
Did you have a prior coverage?
No, I did not.
Yes, I did.
Company Name
*
Prior Policy Number
*
How long did you have prior coverage?
*
Policy Expiration Date
*
Date Format: MM slash DD slash YYYY
Prior Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Describe any loses declared under prior coverage:
Deductible Paid
Amount of Coverage
*
Mortgage Amount
*
Liability
*
UIM/UM Liability
*
Hired car & non-owned auto?
Yes.
No
Drivers
*
Name
DOB
ACC/Tickets
Credits
Do you smoke?
*
No, I don't.
Yes, I do.
Security Devices:
Smoke Alarm
Dead Bolts
Fire Extinguisher
Dwelling Type
*
Private Dwelling
Condo
Apartment
Auto/HO?
*
No, I don't.
Yes, I do.
Monitor Alarm?
*
No, I don't.
Yes, I do.
Year Built
*
Square Feet
*
Construction
Number of Bathrooms
*
Number of Fireplaces
*
Number of Stories
*
Property Features
Pool
Fenced
Laundry Room
Dogs on Property
Bread(s) of Dog(s)
*
Type of Roof
Age of Roof
Water Heater Type:
*
Tank
Tankless
Location of Water Heater
*
Year of Water Heater
*
Year Dwelling Was Painted
Year Dwelling Was Wired
*
Year Dwelling Was Plumbed
*
Type of Plumming
*
Floor Covering %
*
Schedule Items
Jewelry
Furs
Fine Arts
Other
Other Schedule Items
*
Vehicle Information
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Vin #
Vehicle Driver Name
First
Last
Vehicle Lien Holder
First
Last
Usage of Vehicle
Annual Miles of Vehicle
Event Information
Type of Event
*
Date of Event
*
Date Format: MM slash DD slash YYYY
Coverage Limits Requested
*
$2,000,000/$1,000,000
Above $2,000,000/$1,000,000
Estimated Attendance of Event
*
Number of Scheduled Bouts
*
Commissioner
*
Amount of coverage/deductible? (20K/20K W/ $500 DED.)
*
Date Premium was Sent & How? (1-1-01/FedEx)
*
Attach a list any additional insureds, with address:
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