New Website Quote Request (Step 2 of 2) This field is hidden when viewing the formHello! 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.This field is hidden when viewing the formEmail Property Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Is your mailing address the same as your property address?* Yes No Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Is this a new home purchase?* Yes No How long have you lived at your current 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 Closing Date* MM slash DD slash YYYY Name of Lender or Bank*Name of Insured (if different than name listed previously)* First Last Date of Birth* MM slash DD slash YYYY 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 PremiumHave 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 Add DriversAdd VehiclesCurrent Insurance Provider*Current Insurance PremiumHave 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 Add Recreational VehicleIs the garaging address the same as your home address?* Yes No 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) Not Applicable Select all that applyWhat type of Life Insurance Coverage are you looking for?* Whole Life Term Life Universal Life Unsure Select all that applyDeath Benefit Value*$10,000$15,000$25,000$50,000$100,000$250,000$500,000$750,000$1,000,000UnsureIf you are unsure, click here to view our life insurance need calculator: https://www.plattinsurance.com/how-much-life-insurance-do-i-need/ 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
