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Jacob Menaker
2023-06-13T10:32:00-07:00
"
*
" indicates required fields
Types of Insurance
*
Home
Renters
Auto
Motorcycle
Life
Boat
Umbrella
Date Policies Should Start
*
MM slash DD slash YYYY
Name
*
First
Last
Email
*
Phone
*
Can we text you?
*
Yes
No
Consent is not required as a condition of purchase. Message frequency will vary. Message and data rates may apply. Reply HELP for help or STOP to cancel.
Privacy Policy
.
Current Address
Mailing Address
*
Street Address
Address Line 2
City
- Select State -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Current Address
*
Same as Mailing Address
Street Address
Address Line 2
City
- Select State -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Applicant
Date of Birth
*
Month
Day
Year
Gender
*
- Select -
Female
Male
Prefer not to answer
Drivers License Number
*
Drivers License State
*
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Motorcycle Endorsement?
No
Yes
Marital Status
- Select -
Single
Married
Domestic Partner (Unmarried)
Widowed
Separated
Divorced
Fiance or Fiancee
Other
Unknown
Civil Union / Registered Domestic Partner
Occupation
Education Level
- Select -
No High School Diploma or GED
High School
Associate Degree
Bachelor's Degree
Graduate or Professional Degree
Some College
Other
Prefer Not to Answer
Is there a Co-Applicant?
No
Yes
Co-Applicant
Co-Insured Name
*
First
Last
Co-Insured Date of Birth
*
Month
Day
Year
Co-Insured Gender
*
- Select -
Female
Male
Prefer not to answer
Co-Insured Drivers License Number
Co-Insured Drivers License State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Co-Insured Motorcycle Endorsement?
No
Yes
Co-Insured Email
Co-Insured Phone
Co-Insured Occupation
Co-Insured Education Level
- Select -
No High School Diploma or GED
High School
Associate Degree
Bachelor's Degree
Graduate or Professional Degree
Some College
Other
Prefer Not to Answer
Property Information
Property Address
*
Same as Current Address
Street Address
Address Line 2
City
- Select State -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Type of Home
Single Family
Condo
Manufactured
Townhome
Duplex
Triplex
4-Plex
Apartment
Primary Use For Home
Primary Residence
Secondary Residence
Short-Term Vacation Rental (VRBO, AirBnB, etc.)
Short-Term Rental (Less than 6 months)
Long-Term Rental (Greater than 6 months)
Is property titled in a name Other Than your personal name(s)?
*
Example: Trust, LLC, Corporation, Partnership, etc.
No
Yes
Name on Title of Property
*
Is this a New Purchase?
No
Yes
Purchase Date
*
MM slash DD slash YYYY
Purchase Price
Will you do a major renovation on this property shortly after you purchase it?
No
Yes
Will there be a Mortgage?
*
No
Yes
Are there multiple dwellings on this property?
No
Yes
Additional Property Coverage Interests
None
Flood
Earthquake
Hurricane
Have Dogs?
No
Yes
Breed(s) of Dog(s)
Home Information
Is home newly built?
No
Yes
Home Currently Under Construction?
*
No
Yes
Year Built
*
Square Feet
*
# of Bedrooms
# of Bathrooms
# of Stories
Construction Type
- Select -
Frame
Masonry
Log
Concrete
Steel
Fire Resistive / Superior
Trailer / Mobile Home
Other
Roof Type
- Select -
Composition
Tile
Tar and Gravel
Metal
Wood Shake / Shingle
Rock
Other
Foundation Type
- Select -
Crawl Space
Slab-on-Ground
Basement, Daylight
Basement, Below Grade
Basement, Walkout
Open Foundation
Posts and Piers
Suspended Over Hillside
Other
Garage Type
- Select -
Attached
Buiklt-In
Carport
Detached
Basement
Open Lot
Other
Garage Number of Vehicles
Security System
None
Local Security System (Ring, etc.)
Central Station Monitoring System
Primary Heating Type
- Selet -
Baseboard
Electric
Gas
Fireplace
Heat Pump
Oil
Solid Fuel
Space Heater
Wood Stove
Wood Furnace
Other
Does Home Have Central AC?
Yes
No
Number of Water Heaters
1
2
3
4
5
Has Wood Burning Stove?
*
No
Yes
Has Fireplace?
*
No
Yes
Has In-Ground Pool?
*
No
Yes
Has there been any updates to the Roof, Plumbing, Heating, or Electrical?
No
Yes
Roof Update Year
Plumbing Update Year
Heating Update Year
Electrical Update Year
Solar Panels?
No
Yes
Number of Solar Panels
Value of Solar Panels
Does your home qualify for discounts?
(Check all that apply)
Deadbolts
Fire Extinguisher
Smoke Alarm
Monitored Smoke Alarm
Monitored Burglar Alarm
Gated Community
Mature Age
Indoor Spinklers
Electric Backup Generator
Gas Leak Detector
Water Leak Detector
Live-in Caretaker
Lightning Protection
Water Flow Alarm
Patrolled
CCTV
Motion Detector
Wind Mitigation
Mortgage Free
Military
First Responder
Does home have any detached structures?
Yes
No
What types of detached structures?
Fence
Guest House
Pool House
Shed
Deck
Other
Other type of detached structure
Does home have an elevator?
Yes
No
Photos of Home (Optional)
If you would like to attach any pictures of your home inside and/or outside, please do so here.
Drop files here or
Select files
Max. file size: 3 MB, Max. files: 6.
Additional Drivers
Are there additional drivers in your household?
No
Yes
Additional Driver 1
1. Driver Name
*
First
Last
1. Driver Date of Birth
*
MM slash DD slash YYYY
1. Gender
*
- Select -
Female
Male
Prefer not to answer
1. Relationship to Insured
*
- Select -
Spouse
Child
Domestic Partner
Parent
Relative
Employee
Other
1. Driver License #
*
1. Drivers License State
*
- Select State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Add 2nd Driver
Add Another Driver
Additional Driver 2
2. Driver Name
*
First
Last
2. Driver Date of Birth
*
MM slash DD slash YYYY
2. Gender
*
- Select -
Female
Male
Prefer not to answer
2. Relationship to Insured
*
- Select -
Spouse
Child
Domestic Partner
Parent
Relative
Employee
Other
2. Driver License #
*
2. Drivers License State
*
- Select State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Add 3rd Driver
Add Another Driver
Additional Driver 3
3. Driver Name
*
First
Last
3. Driver Date of Birth
*
MM slash DD slash YYYY
3. Gender
*
- Select -
Female
Male
Prefer not to answer
3. Relationship to Insured
*
- Select -
Spouse
Child
Domestic Partner
Parent
Relative
Employee
Other
3. Driver License #
*
3. Drivers License State
*
- Select State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Add 4th Driver
Add Another Driver
Additional Driver 4
4. Driver Name
*
First
Last
4. Driver Date of Birth
*
MM slash DD slash YYYY
4. Gender
*
- Select -
Female
Male
Prefer not to answer
4. Relationship to Insured
*
- Select -
Spouse
Child
Domestic Partner
Parent
Relative
Employee
Other
4. Driver License #
*
4. Drivers License State
*
- Select State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Vehicle 1
1. VIN
1. Year
*
1. Make
*
1. Model
*
1. Estimated Annual Miles
1. Primary Use
Pleasure
To/From Work
Business
1. Ownership
Own
Lease
1. Vehicle Financed
No
Yes
1. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
1. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
Add 2nd Vehicle
Add a Vehicle
Vehicle 2
2. VIN
2. Year
*
2. Make
*
2. Model
*
2. Estimated Annual Miles
2. Primary Use
Pleasure
To/From Work
Business
2. Ownership
Own
Lease
2. Vehicle Financed
No
Yes
2. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
2. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
Add 3rd Vehicle
Add a Vehicle
Vehicle 3
3. VIN
3. Year
*
3. Make
*
3. Model
*
3. Estimated Annual Miles
3. Primary Use
Pleasure
To/From Work
Business
3. Ownership
Own
Lease
3. Vehicle Financed
No
Yes
3. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
3. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
Add 4th Vehicle
Add a Vehicle
Vehicle 4
4. VIN
4. Year
*
4. Make
*
4. Model
*
4. Estimated Annual Miles
4. Primary Use
Pleasure
To/From Work
Business
4. Ownership
Own
Lease
4. Vehicle Financed
No
Yes
4. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
4. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
Add 5th Vehicle
Add a Vehicle
Vehicle 5
5. VIN
5. Year
*
5. Make
*
5. Model
*
5. Estimated Annual Miles
5. Primary Use
Pleasure
To/From Work
Business
5. Ownership
Own
Lease
5. Vehicle Financed
No
Yes
5. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
5. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
Add 6th Vehicle
Add a Vehicle
Vehicle 6
6. VIN
6. Year
*
6. Make
*
6. Model
*
6. Annual Miles Driven
6. Primary Use
Pleasure
To/From Work
Business
6. Ownership
Own
Lease
6. Vehicle Financed
No
Yes
6. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
6. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
Special Motorcycle Coverages
Enhanced Injury Protection
Yes
No
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
$1 - $3,000
$3,001 - $4,000
$4,001 - $5,000
$5,001 - $6,000
$6,001 - $7,000
$7,001 - $10,000
$10,001 - $15,000
$15,001 - $20,000
$20,001 - $25,000
$25,001 - $30,000
Safety & Riding Apparel
$1 - $500
$501 - $1,000
$1,001 - $1,500
$1,501 - $2,000
$2,001 - $2,500
$2,501 - $3,000
Transport Trailer Coverage?
No
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
- Select -
Fiberglass
Aluminum
Wood
Inflatable
Steel
Other
Number of Motors
1
2
3+
Propulsion Type
- Select -
Inboard
Outboard
Inboard / Outboard
Jet
Max Horsepower
Max Speed
Current Value
Fishing Equipment Coverage
None
$1,000
$2,500
$5,000
$10,000
Insure the Trailer?
Yes
No
Umbrella Coverage Information
Number of Properties
1
2
3
4
5
6
7
8
9
10
Number of Vehicles
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Number of Drivers
1
2
3
4
5
6
7
8
9
10
Any drivers under age 25?
No
Yes
Any drivers over age 75?
No
Yes
Liability Limit
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$10,000,000
$20,000,000
Greater than $20,000,000
Life Insurance
Primary Applicant: Amount of Coverage
*
- Select -
$1 - $100k
$100k - $200k
$200k - $300k
$300k - $400k
$400k - $500k
$500k - $600k
$600k - $700k
$700k - $800k
$800k - $900k
$900k - $1 Million
$1 Million - $2 Million
$2 Million - $5 Million
$5 Million or greater
Primary Applicant: Duration
*
- Select -
10 years
15 years
20 years
30 years
Does Primary Applicant Have a Current Life Policy?
No
Yes
Primary Applicant: Height
Feet and Inches
Primary Applicant: Weight
Pounds (lbs)
Does Co-Insured Want Life Insurance?
No
Yes
Co-Insured: Amount of Coverage
*
- Select -
$1 - $100k
$100k - $200k
$200k - $300k
$300k - $400k
$400k - $500k
$500k - $600k
$600k - $700k
$700k - $800k
$800k - $900k
$900k - $1 Million
$1 Million - $2 Million
$2 Million - $5 Million
$5 Million or greater
Co-Insured: Duration
*
- Select -
10 years
15 years
20 years
30 years
Does Co-Insured Have a Current Life Policy?
No
Yes
Co-Insured: Height
Feet and Inches
Co-Insured: Weight
Pounds (lbs)
Wrapping Up
Any Claims in the Past Three (3) Years?
*
No
Yes
Please describe past claims
*
Do you need any SR-22 filings?
*
No
Yes
Additional Comments
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Drop files here or
Select files
Max. file size: 12 MB.
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Jacob Menaker
Alejandro Castro
Yuliannis Diaz
Amanda Perez
Jessica Bernal
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*
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