LCIS Agency New Client Questionnaire
Please answer all the questions on this form. I look forward to providing as much value as possible and protecting the things that are important to you. Once received, I'll get started right away working on your quotes. By filling out this form, you give us permission to communicate with you via text, email, and phone call.
Full Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone Number
*
-
Area Code
Phone Number
What is most important to you about your insurance?
Price
Agent
Adequate Coverage
How pleased are you with your current Insurance advisor?
They are awesome!
Average, I suppose
I'm not satisfied with them
How can we help with your Insurance needs
*
Just an auto insurance quote
Car and Home/Renters Bundle Quote
Life Insurance Quote
Car and Home/Renters and Life Bundle
Back
Next
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
On a scale of 1-5 (5 is the most healthy), how would you rate your overall health?
*
5
4
3
2
1
Do you use tobacco products?
*
Yes
No
Number of vehicles
*
1
2
3
4
5
Car 1 Year/Make/Model or VIN
Car 2 Year/Make/Model or VIN
Car 3 Year/Make/Model or VIN
Car 4 Year/Make/Model or VIN
Car 5 Year/Make/Model or VIN
Number of Drivers
1
2
3
4
5
Driver #1
*
First Name
Last Name
Driver 1: DOB
*
-
Month
-
Day
Year
Date
Driver #2
*
First Name
Last Name
Driver 2: DOB
*
-
Month
-
Day
Year
Date
Driver #3
*
First Name
Last Name
Driver 3: DOB
*
-
Month
-
Day
Year
Date
Driver #4
*
First Name
Last Name
Driver 4: DOB
*
-
Month
-
Day
Year
Date
Driver #5
*
First Name
Last Name
Driver 5: DOB
*
-
Month
-
Day
Year
Date
Do you currently have Auto insurance??
*
Yes
No
How much is your current Auto Insurance monthly?
Do you own or rent your home?
Own
Rent
How much building coverage is required for your home policy?
What year was your roof replaced?
How much in personal contents coverage do you need for your renters policy?
Do you currently have home insurance?
Yes
No
Do you currently have renters insurance?
Yes
No
Are there any other details that would help in the quote process? (Accidents or moving Violations)
Submit
Should be Empty: