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C4 Insurance
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C4 Insurance
PL Quote Request
Rehab Quote Request
REIA Member Quote
Contact
Proud to partner with
Scott Petersburg.
We are ready to start a project of any complexity.
Call us now!
608.824.7267
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Customer Information
2
Spouse Information
3
Home Insurance Information
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CUSTOMER INFORMATION
Name
*
First
Middle
Last
Gender
Date of birth
*
Date Format: MM slash DD slash YYYY
Email
Phone
Current/Purchase property address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Own
Rent
How Long/purchase date if new?
Occupation
Previous address if less than three years at current address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
OK to run credit for insurance purposes?
Yes
No
How did you hear about us?
SPOUSE INFORMATION (IF JOINT APPLICATION)
Name
First
Middle
Last
Gender
Date of birth
Date Format: MM slash DD slash YYYY
Email
Occupation
HOME INSURANCE INFORMATION
Current Carrier
Time with Current Carrier
Current Policy Expiration Date
Date Format: MM slash DD slash YYYY
Current Policy Premium
Please describe any losses/claims in the last five years
CURRENT/PURCHASE POLICY COVERAGE
Dwelling Amount
Other Structures
Personal Property
Liability:
Medical
Deductible
RATING INFORMATION (Please circle option if listed)
Year Built
Style
ranch
contemporary
colonial
craftsman
bungalow
Number of Stories
Exterior
wood
vinyl
brick
stucco
other
Square Feet Above Ground
Basement
standard
exposed
walkout
% Finished
Feet to Fire Hydrant
Miles to Fire Department
Number of Full Bathrooms
3/4 Bathrooms
1/2 Bathrooms
Bathroom Grade
builders
custom
designer
Kitchen Grade
builders
custom
designer
Garage
Attached
Detached
# of stalls
Other Structures
shed
barn
other
Fireplace
Yes
No
Type of Fireplace
wood
gas
Deck Material
Deck Size
Porch
Yes
No
Porch Type
screened
enclosed
open
Porch Size
Swimming pool
Yes
No
Pool Type
fenced
interior
Trampoline
Yes
No
Trampoline Type
Fenced
Unfenced
Any pets
Yes
No
Pet breeds and number
Incidental Business
Yes
No
If yes, please describe
DISCOUNTS AND OPTIONAL COVERAGE QUESTIONS
Updated Age of Roof
Wiring
Heating
Plumbing
Central Burglar Alarm
Yes
No
Non- Smoker
Yes
No
Umbrella Policy
Yes
No
Do you need to schedule Personal Property like Jewelry, Art, Guns, etc.?
Yes
No
If Yes please describe
AUTO INSURANCE INFORMATION
Current Carrier
Time with Current Carrier
Current Policy Expiration Date
Date Format: MM slash DD slash YYYY
Current Policy Premium
CURRENT POLICY COVERAGE (Please circle option if listed)
Bodily Injury Limit
Property Damage
Medical Expense
Uninsured Liability
Underinsured Liability
Comprehensive Deductible
Collision Deductible
Towing/Roadside Assistance
Yes
No
Rental Reimbursement
Yes
No
Do you need Gap Coverage?
Yes
No
DRIVER INFORMATION
Driver Name
Date of Birth
Driver’s License Number
Relationship
DRIVING HISTORY AND CLAIMS
Driver Name
Accident or Violation Info (include date and specifics)
At Fault (Y or N)
VEHICLE INFORMATION – AUTOMOBILES and MOTORCYCLES (Please circle option if listed)
Year
Make
Model
VIN
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