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Address: 389 Niles Cortland Rd. NE, Warren, OH 44484
Phone: (330) 856-6244
Email: info@plattinsurance.com

Why Platt?
Products
Service Center
- Billing
- Claims
- Policy Service
- Contact
Resources
- Learning Center
Contact Us

Life & Financial

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Would You Like Us To Review Your Policies?

1Start

2Contact Info

3Home Quote

4Auto Quote

5Toys Quote

6Life Quote

7Other Quote

8Referral

Hello! What would you like a quote for?*
- Auto
- Home / Condo
- Tenant
- Business
- Umbrella
- Rental Property
- Motorcycle
- Boat
- Life
- Medicare
- Farm Insurace
Check all that apply. You can tell us if there is something else you need a quote for in just a moment.

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Primary Policyholder Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Date of Birth
MM slash DD slash YYYY

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Is the property address the same as your mailing address?*
- Yes
- No
Property Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long have you lived at this address?*
- More than or equal to 5 years
- Less than 5 years
Prior Property Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is this a new home purchase?*
- Yes
- No
Closing Date*
MM slash DD slash YYYY
Name of Lender or Bank*
Name of Spouse or other Deed Holder
First Last
Is your basement finished?*
- Yes
- No
In what year was your roof last replaced?*
Do you have any dogs?*
- Yes
- No
What Breed(s)?
Current Insurance Provider*
Current Insurance Premium
Have you had any insurance claims in the last 5 years?*
- Yes
- No
Are you interested in bundling your home and auto to save on your policies?*
- Yes
- No

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How many Drivers are in your Household?*
Driver 1's Name*
First Last
Driver 1's Date of Birth*
MM slash DD slash YYYY
Driver 2's Name*
First Last
Driver 2's Date of Birth*
MM slash DD slash YYYY
Driver 3's Name*
First Last
Driver 3's Date of Birth*
MM slash DD slash YYYY
Driver 4's Name*
First Last
Driver 4's Date of Birth*
MM slash DD slash YYYY
How many vehicles are in your household?*
Vehicle 1 Year*
Vehicle 1 Make and Model*
Vehicle 2 Year*
Vehicle 2 Make and Model*
Vehicle 3 Year*
Vehicle 3 Make and Model*
Vehicle 4 Year*
Vehicle 4 Make and Model*
Current Insurance Provider*
Current Insurance Premium
Have you had any accidents or violations in the last 5 years?*
- Yes
- No
Are you interested in bundling your home and auto to save on your policies?*
- Yes
- No

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Motorcycle Year*
Motorcycle Make*
Motorcycle Model*
Boat Year*
Boat Make*
Boat Model*
Does your boat have a motor?*
- Yes
- No
Do you have a trailer?*
- Yes
- No
Is the garaging address the same as your home address?*
- Yes
- No

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Name of Insured (if different than name listed previously)
First Last
Date*
MM slash DD slash YYYY
Gender*
- Male
- Female
- I'd prefer not to say
Height*
Weight (lbs)*
Do you use Tobacco Products?*
- Yes
- No
Do you use Marijuana or other CBD Products?*
- Yes
- No
Do you have or have a family history of the following:*
- Heart Disease
- Cancer
- Diabetes
- Mental Disorders (including Depression and/or Anxiety)
Select all that apply
What type of Life Insurance Coverage are you looking for?*
- Whole Life
- Term Life
- Universal Life
- Unsure
Select all that apply
Death Benefit Value*
If you are unsure, click here to view our life insurance need calculator: https://www.plattinsurance.com/how-much-life-insurance-do-i-need/

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Thank you for requesting a quote! A licensed agent will be reaching out by the next business day to gather more information.
List any additional information you would like to provide

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What led you to request this quote?*
- Internet Search
- Social Media
- Referral
- Platt Sign
- Community Event
- Other
Who referred you to us?*

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Howland Location 389 Niles Cortland Rd. NE
Warren, OH 44484
Phone: (330) 856-6244

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_{Disclosure Statement:Securities offered through Nationwide Securities, LLC., member FINRA, SIPC, DBA Nationwide Advisory Services, LLC. in AR, CA, FL, IL, NY, TX and WY. Representative of Nationwide Life Insurance Company, affiliated companies and other companies. Visit FINRA Broker Check}