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Home & Auto Quote Questionnaire

Name: Langer Insurance Agency
Address: 201 Point E Dr., Nashville, TN, 37216, US
Telephone: (615) 351-1298

Email
This field is for validation purposes and should be left unchanged.
Email*
Full Legal Name (As it appears on your Driver's License, Ex: First, Middle and Last)*
Nickname or Preferred Name*
Relationship Status*
Mark only one oval.
- Single
- Married
- Domestic Partner
- Divorced
Date of Birth*
Example: January 7, 2019
Phone Number*
Preferred Method of Communication (Select all that you prefer)*
- Call
- Text
- Email
Select Your Gender*
- Male
- Female
Current Address (New Address if Purchasing)*
Street Address Address Line 2 City State ZIP Code
Have You Moved in the Last 3 Years?*
- Yes
- No
Prior Address (if moved in the last 3 years)*
Street Address Address Line 2 City State ZIP Code
Driver's License Number*
State Licensed*
How long have you owned your vehicle?*
What is your highest level of education?*
Mark only one oval.
- Some high school
- High school diploma or GED
- Some college
- Currently in college
- College degree
- Graduate work or graduate degree
- Vocational/ trade school or military
What is your occupation?*
Who is your Employer? (Company Name)*
Company Mailing Address*
How did you hear about us? Referrals help our business grow!*
Example: Person’s Name, Reddit, Google, Mortgage Lender (Specify Name), Social Media Platforms
Spouse/Domestic Partner Information
Full Legal Name (As it appears on your Driver's License, Ex: First, Middle and Last)*
Nickname or Preferred Name*
Gender*
- Male
- Female
Date of Birth*
Example: January 7, 2019
Phone Number*
Email Address*
Driver's License Number*
State Licensed*
What is their highest level of education?*
Mark only one oval.
- Some high school
- High school diploma or GED
- Some college
- Currently in college
- College degree
- Graduate work or graduate degree
- Vocational/ trade school or military
What is their occupation?*
Who is their Employer? (Company Name)*
Company Mailing Address*
Home / Renters Insurance
What Type of Home is This?*
Mark only one oval.
- Primary Residence: Own or Purchasing
- Primary Residence that you are Renting
- Secondary Home: Own or Purchasing
- Income Property: Own and Rent to Others
Type of Rental Arrangement*
- Leased
- Airbnb/Vrbo
Who Is Your Current Home/Renters Insurance Provider?*
Year of HVAC (if homeowner):*
Year of Roof (if homeowner):*
Are you Planning Any Renovations?*
Mark only one oval.
- Yes
- No
What is the Square Footage of your House?*
Is there a pool?*
Mark only one oval.
- Yes
- No
If So, What Type of Pool and What Is the Square Footage?*
In-Ground / Above-Ground
Is It Secured With a Locked Fence?*
Mark only one oval.
- Yes
- No
Is there a garage or carport? What type?*
Attached or Detached, 1-car or multiple car
How many full baths?*
How many half baths?*
What type of foundation?*
Mark only one oval.
- Slab
- Crawl space
- Basement
If there is a basement, what percent is finished?*
Have You Had Any HOME Claims in the Last 5 Years?*
- Yes
- No
Please List*
Any Pets? If Yes, Please Specify How Many, Their Breeds, and Any Bite History*
Do You Own Any Jewelry or High-Value Items (Over $3,000) That Need to Be Scheduled?*
(Ex: Wedding Rings/Bands, Rolexes, Music Equipment, Handbags, etc) If Yes, Describe What It Is in Detail (Cut/Color/Carat), Its Value, and Whether You Have an Appraisal.
Your Car (Car 1)
Bundling home and auto tends to save quite a bit of money. If you're interested, we'd love to take a look at the rates for you.
Who is your current auto insurance provider?*
VIN and Type of Car*
This can be found on your current auto insurance card
Is the Vehicle Used for Ridesharing or Other Business? (Uber, Lyft, DoorDash, Real Estate, Construction)*
Mark only one oval.
- Yes
- No
Who is this Vehicle Titled To?*
List all Names on the Title
What is the average amount of miles per year on your car?*
Mark only one oval.
- 8K
- 12K
- 15K
- Others
Have You Had Any Tickets, Suspensions, DUI's, or Auto Claims in the Last 5 Years?*
- Yes
- No
Please List*
Car 2 (If applicable)
Other Drivers must be a resident of your household in order to be on your policy
VIN and Type of Car
This can be found on your current auto insurance card
Is the Vehicle Used for Ridesharing or Other Business? (Uber, Lyft, DoorDash, Real Estate, Construction)
Mark only one oval.
- Yes
- No
What is the average amount of miles per year on that car?
Mark only one oval.
- 8K
- 12K
- 15K
- Others
Who Drives This Vehicle if You Have Multiple Cars?
Who is this Vehicle Titled To?
List all Names on the Title
Has Driver #2 Had Any Tickets, Suspensions, DUI's, or Auto Claims in the Last 5 Years?
- Yes
- No
Please List
Other Drivers (if applicable)
Other Drivers Must Be a Resident of Your Household in Order to Be on Your Policy (Ex: Licensed Children or Parents)
Full Legal Name (As it appears on your Driver's License, Ex: First, Middle and Last)
Select Your Gender
- Male
- Female
Date of Birth
Example: January 7, 2019
Driver's License Number
State Licensed
Phone Number
VIN and Type of Car
This Can Be Found on Your Current Auto Insurance Card
Has the Driver Had Any Tickets, Suspensions, DUI's, or Auto Claims in the Last 5 Years?
- Yes
- No
Please List
Who is this Vehicle Titled To?
List all Names on the Title
What is the average amount of miles per year on that car?
Mark only one oval.
- 8K
- 12K
- 15K
- Others
Other Drivers (if applicable)
Other Drivers must be a resident of your household in order to be on your policy
Full Legal Name (As it appears on your Driver's License, Ex: First, Middle and Last)
Select Your Gender
- Male
- Female
Date of Birth
Example: January 7, 2019
Driver's License Number
State Licensed
Phone Number
VIN and Type of Car
This Can Be Found on Your Current Auto Insurance Card
What is the average amount of miles per year on that car?
Mark only one oval.
- 8K
- 12K
- 15K
- Others
Has the Driver Had Any Tickets, Suspensions, DUI's, or Auto Claims in the Last 5 Years?
- Yes
- No
Please List