225-465-2075
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Commercial Insurance
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Contact Us
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GET A QUOTE
About Us
News
Commercial Insurance
Personal Insurance
Contact Us
Careers
225-465-2075
GET A QUOTE
Email:
[email protected]
Hours: Mon - Fri: 8:00 - 5:30
225-465-2075
About Us
News
Commercial Insurance
Personal Insurance
Contact Us
Careers
GET A QUOTE
About Us
News
Commercial Insurance
Personal Insurance
Contact Us
Careers
225-465-2075
GET A QUOTE
Get A Quote
Personal Automobile Quote
Homeowner Quote
Commercial Questionnaire
Personal Automobile Quote
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Name:
*
First
Last
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Address:
*
Street Address
City
ZIP Code
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Phone #:
*
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Email Address:
*
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Homeowner:
*
Yes
No
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DOB:
*
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SS#:
*
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DL#:
*
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Highest Education Received:
*
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Occupation/Employer:
*
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# Years:
*
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Married:
*
Yes
No
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Spouse's Name:
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DOB:
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SS#:
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DL#:
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Occupation/Employer:
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# Years:
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Highest Education Received:
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ADDITIONAL Drivers in Household:
Name:
DOB:
SS#:
DL#
Occupation:
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Driver's Training:
*
Yes
No
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Which Drivers:
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Good Student (3.0 GPA or Higher):
Yes
No
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Which Students:
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Current Insurance
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Company:
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Renewal Date:
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Policy #:
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Current liability limits carried:
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# years with current company:
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Tickets or Accidents (AF or NAF in past 5 years):
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Claims in last 5 years (windshield, windshield repair, fire, theft, vandalism):
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Year
Make
Model
VIN
Use (Personal/Work)
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Bodily Injury
$50,000
$100,000
$300,000
Medical Payments
$25,000
$50,000
>$50,000
Property Damage:
$50,000
$250,000
$500,000
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Uninsured Motorist:
Yes
No
Towing & Labor:
Yes
No
Remove & Replace:
Yes
No
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Year
Make
Model
VIN
Use
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Bodily Injury
$50,000
$100,000
$300,000
Medical Payments
$25,000
$50,000
>$50,000
Property Damage:
$50,000
$250,000
$500,000
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Uninsured Motorist:
Yes
No
Towing & Labor:
Yes
No
Remove & Replace:
Yes
No
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Year
Make
Model
VIN
Use
Untitled
Untitled
Bodily Injury
$50,000
$100,000
$300,000
Medical Payments
$25,000
$50,000
>$50,000
Property Damage:
$50,000
$250,000
$500,000
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Uninsured Motorist:
Yes
No
Towing & Labor:
Yes
No
Remove & Replace:
Yes
No
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Year
Make
Model
VIN
Use
Untitled
Untitled
Bodily Injury
$50,000
$100,000
$300,000
Medical Payments
$25,000
$50,000
>$50,000
Property Damage:
$50,000
$250,000
$500,000
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Uninsured Motorist:
Yes
No
Towing & Labor:
Yes
No
Remove & Replace:
Yes
No
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Homeowner Quote
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Owners:
Name
DOB
SSN#
Occupation
Phone Number
Marital Status
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Number of children under 18 years old?
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Current Address:
*
Street Address
City
ZIP Code
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New Address:
Street Address
City
ZIP Code
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Parish:
*
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City Limits:
*
Y
N
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Email
*
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New Purchase:
*
Yes
No
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Yes - Closing Date:
No - Date Purchased:
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Is there a mortgage on the home?
*
Y
N
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Purchase Price:
*
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Current Carrier:
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Current Coverage:
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Current Expiration Date:
*
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Claim in past 5 years:
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Year Built:
*
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Stories:
*
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# of Bathrooms:
*
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Sq. Ft. Living:
*
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Age of Roof:
*
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Foundation:
*
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Roof Structure:
*
Hip
Gable
Flat
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Floors (carpet, wood, laminated, tile, etc.) & %:
*
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Wall Surface (paint, paper, paneling, etc.) & %:
*
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Heat:
*
Gas
Electric
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Central Air/Heat:
*
Y
N
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Fireplace:
*
Y
N
How Many:
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Chimney:
Metal
Brick
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If acreage, how much:
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Carport/Garage:
*
Y
N
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Garage Type:
Detached
Attached
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# of Cars:
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Porch/Deck/Patio:
*
Y
N
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Sq. Ft.:
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Screened:
Y
N
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Detached Structures, Utility Shed, Fence, etc. (include value):
*
Y
N
If yes, describe:
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Pool:
*
Y
N
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Pool Type:
In-Ground
Above Ground
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Fenced:
*
Y
N
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Locked Gate:
Y
N
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Pool Accessories:
Slide
Diving Board
Both
None
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Trampoline:
*
Y
N
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Dogs:
*
Y
N
Breed(s):
*
How Many:
*
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Plumbing (updates required if older than 20 yrs):
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Heating (updates required if older than 20 yrs):
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Wiring (updates required if older than 20 yrs):
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Optional Coverages (Jewelry, Fur, Silver, ATV, etc.):
*
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Discounts:
Military
Smoker
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Alarm:
Local
Monitored
Burglary
Fire
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Company Name:
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Flood Quote:
*
Y
N
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Flood Quote on:
Building
Contents
Both
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Elevation Certificate?
*
Y
N
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Commercial Questionnaire
APPLICANT NFORMATION
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Business Name:
*
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DBA:
*
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Mailing Address:
*
Street Address
City
ZIP Code
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Property Address:
*
Street Address
City
ZIP Code
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Years in Business:
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Years Experience:
*
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FEIN/SSN:
*
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Contact:
*
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Phone #:
*
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Cell #:
*
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Email Address:
*
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Website:
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Prior Carrier for all lines and expiring/current premium:
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Description of Operations:
*
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GERNERAL LIABILITY
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Sales:
*
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Payroll:
*
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# of Emloyees:
*
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Additional Insured:
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Subcontractors:
*
Yes
No
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Type of Work Done by Subs:
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Annual Cost of Subs:
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% of Work Performed by Subs:
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% of Commercial:
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% of Residential:
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