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618 Insurance Agency

(618) 433-8880
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Your Name*
First Last
Your Email*
Check the box to provide permission to receive emails from 618 Insurance.*
- I agree.
Your Cell Phone Number*
Your Current Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Preferred Means of Contact*
- Email
- Phone
- Text Message
Check the box to provide permission to receive text messages from 618 Insurance. (Message and Data Rates may apply)*
- I agree.
Your Highest Level of Education*
Your Occupation*
Your Marital Status
Spouse's/Significant Other's Name
First Last
Your Spouse/Significant Other's Highest Level of Education
Your Spouse's Occupation
What brings you to us?*
- Buying a new home
- Referred By Friend
- Unhappy with prior agent
- Concerned about my current insurance price
- Cancelled by prior carrier
- Just checking out my prices...
- HEARD AWESOME THINGS ABOUT SIDEBAR!
What type of insurance are you seeking?
- Home Insurance
- Auto Insurance
- Umbrella Insurance
- Motorcycle Insurance
- Boat Insurance
Do you currently have insurance?*
- Yes
- No
- I haven't needed it before
Name of current carrier
How many years have you been with your current carrier?

Home Insurance Section
You ____ the home you live in.
- Own
- Own with Mortgage
- Rent
- Live with someone else who owns/pays rent
What is the approximate square footage of your home?
Does your home have any of the following?
- Trampoline
- Pool
- Home Insurance claims in the past
- Dog(s)
- Exotic Pets
Is your trampoline...
- in a fenced yard.
- staked in the ground.
- surrounded by a net.
Does your pool have...
- a fence
- a diving board
- a slide
- a permanent ladder
- a removable ladder.
- in ground
- above ground
How many dogs do you have?
Have any of your dogs/other pets previously bitten anyone?*
- Yes
- No
Are you willing to exclude animal bites from your home's liability coverage?*
- Yes
- No
Breed of dog 1
Breed of dog 2
Breed of dog 3
What kind of exotic pet?
How old is your roof?
How old is Heating/Air Conditioning?
How old is the electrical?
How is the electrical system controlled?
- Circuit Breakers - metal box with switches
- Fuse Box - metal box where you screw in fuses
Does your home's electrical system have:*
- Knob and Tube wiring
- Romex wiring
- Electrical Service less than 200 Amps
- None of the above

Auto Insurance Section
How many drivers in your household?
How do you want to provide driver's license information?
- Provide over the phone.
- Text photos of driver's license to (708) 942-5150
- Email photos to adam@sidebarinsurance.com
Name of Driver #1
First Last
Driver #1 Date of Birth
MM slash DD slash YYYY
Driver's License Number for Driver #1
Name of Driver #2
First Last
Driver #2 Date of Birth
MM slash DD slash YYYY
Driver's License Number for Driver #2
Name of Driver #3
First Last
Driver #3 Date of Birth
MM slash DD slash YYYY
Driver's License Number for Driver #3
Name of Driver #4
First Last
Driver #4 Date of Birth
MM slash DD slash YYYY
Driver's License Number for Driver #4
Name of Driver #5
First Last
Driver #5 Date of Birth
MM slash DD slash YYYY
Driver's License Number for Driver #5
How many cars do you own?
What type of car #1? (year/make/model)
VIN Number for car #1
Car #1 is:
- Owned outright
- has a loan on it.
- is leased.
What type of car #2? (year/make/model)
VIN Number for car #2
Car #2 is:
- Owned outright
- has a loan on it.
- is leased.
What type of car #3? (year/make/model)
VIN Number for car #3
Car #3 is:
- Owned outright
- has a loan on it.
- is leased.
What type of car #4? (year/make/model)
VIN Number for car #4
Car #4 is:
- Owned outright
- has a loan on it.
- is leased.
What type of car #5? (year/make/model)
VIN Number for car #5
Car #5 is:
- Owned outright
- has a loan on it.
- is leased.
Do any of your household drivers have the following:
- Moving Violations/Tickets over the past five years
- Motor Vehicle accidents in the past five year
- Roadside Assistance claims over the past five years

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618 Insurance Agency

3021 Godfrey Rd
PO Box 5233
Godfrey, IL 62035

(618) 433-8880

ryan@618ins.com

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