Get a Quote

Please select the type of insurance you need.

Capstone protects your confidentiality and uses industry standards to secure the transmission of this form submittal (refer to Privacy Statement). Quote proposals we provide depend on the completeness and accuracy of the information you give us. If you are unsure about a question, please leave it blank.

Personal Information

Desired Start Date of Policy

Date of Birth

SSN



Many of our insurance carriers use a credit and claims based proprietary model to generate an insurance score for rating. While you are not required to provide your SSN during the quoting stage, the use of your SSN assures accurate rating and helps us gather additional information from consumer reporting agencies. We use your SSN solely for our business of providing insurance services and never disclose information in an unauthorized way. Capstone uses industry standards of security to safeguard your information. Your SSN is used for insurance rating purposes only and does not affect your credit score.

123-12-1234

Marital Status

Name *

First

Middle

Last

Suffix

Phone Number *

Email *

Confirm Email *

Occupation

Current Mailing Address

Street, Apt/STE

City

State

Zip Code

Have you moved in the last 2 years?

Prior Address if less than 2 Years

Prior Street, Apt/STE

Prior City

Prior State

Prior Zip Code

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Residence Information

Property Address You Want to Insure

Insure Property at a Different Address from Mailing

Property Street, Apt/STE

Property City

Property State

Property Zip Code

Type of Dwelling/Residence:

Occupancy of Property

Property Form of Ownership:

Usage of the Property

Any short-term rental exposure?

Number of families that reside in the home/dwelling?

Any business conducted on property that involves customers visiting your home/dwelling?

E.g., Daycare, Salon, etc

Is the property currently under construction or renovation?

Indicate any animals that live at the residence address.

May have multiple selections.

Is the property on more than 5 acres?

Is the property for sale or in foreclosure?

Residence Comments

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Structure Details

Year Built

Living Area Square Footage

Porch or Deck Square Footage

Any porches or decks 3' or higher without handrails?

Primary Siding Type (60% or more)

Foundation Type

Number of Stories

Garages and Carports

Is there a swimming pool on the premises?

Is there a trampoline on the premises?

Are there bars on the windows?

Do you have an alarm system?

Does the home/residence have solar panels?

Any sidewalk, driveway, walkway, or steps cracked or lifting?

Roof Details

Roof Type

Roof Shape

Year Roof Replaced

Does the roof show signs of aging - lifting, curling, missing shingles or unrepaired damage or debris accumulation?

Is any part of the roof over living area flat?

Utility Details

Electrical - any fuses, Knob & Tube, cloth, or aluminum wiring?

Year Electrical Updated

Does the residence/home have central air conditioning?

Is the primary heating system centrally and thermostaically controlled?

Year Heat Updated

Any secondary heating sources (besides a fireplace)?

Is there a fuel tank on premise?

Plumbing Type

Year Plumbing Updated

Structure Comments

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Final Homeowner Details

Desired Coverage amount or replacement cost of the home/dwelling (exclude land value)

Measured in thousands (e.g.,___,000)

Which deductible would you like?

The deductible amount is the portion you pay before insurance begins to cover a loss in a claim and is often deducted from the total payment.

Do you currently have insurance on the property?

Prior Policy Expiration Date

Prior Liability Amount

Have you had any property insurance claims or losses at this location or any other location in the past 6 years?

Yes, I have had property insurance claims or losses in the past 6 years.

Type of Loss

Date of Loss

Approximate Amount Paid of Loss

+ Add Another Claim or Loss

- Remove Last Claim or Loss

Has property insurance been declined, non-renewed, or cancelled in the past years?

If yes, please explain

Final Comments

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Flood Information

Name *

First

Middle

Last

Phone Number *

Email *

Current Mailing Address

Street, Apt/STE

City

State

Zip Code

Property Address You Want to Insure

Insure Property at a Different Address from Mailing

Property Street, Apt/STE

Property City

Property State

Property Zip Code

Is this for a new purchase?

If yes, does the seller have an active flood policy?

Is there an elevation certificate for the property?

Are there multiple Structures on the property?

Effective Date

Is the building a condo?

Original Construction Year

Property Purchase Date

Have you ever had a flood policy for this property location?

Is the building a rental property?

Are you a tenant?

Building Occupancy

Building Under Construction?

Building Partially or Entirely Over Water

Percentage of the year that you or your spouse lives in the building?

Square Footage

Do you have an elevation certificate?

Garage attached to or part of the building?

Foundation Type

Number of Floors

Building Coverage Amount

Max $250,000

Contents Coverage

Max $100,000

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Coverages & Limits

Current Insurance Company

Policy #:

Auto Policy Expiration Date

How long continuous insurance?

How long with current carrier?

Is policy being non-renewed?

Reason for Non-Renewal

Current Auto Liability Limits

Current Uninsured Motorists Limits

Medical Payments

UM Property Damage?

Do you currently have an accident-free discount on policy?

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Vehicle Information

Vehicle Year

Vehicle Make

e.g., Chevrolet, Nissan, Toyota, etc.

Vehicle Model

e.g., Silverado, Altima, Camry, etc.

VIN (Serial Number)

Principal Operator

Use

Owned, Leased, or Financed?

If To & From Work, # of Miles One Way

Comprehensive Deductible

Collision Deductible

Towing

Rental Reimbursement

ABS

Alarm

VIN Etching

Air Bags

Vehicle Used for Rideshare

e.g., Uber, Lyft, etc.

Vehicle Used for Delivery

Excluding Rideshare

Vehicle Purchase Date

+ Add Another Vehicle

- Remove Last Vehicle

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Driver Information

Please list all members of household 14 years or older.

Driver's Name

First

Middle

Last

Suffix

Driver's License #

Date of Birth

Many of our insurance carriers use a credit and claims based proprietary model to generate an insurance score for rating. While you are not required to provide your SSN during the quoting stage, the use of your SSN assures accurate rating and helps us gather additional information from consumer reporting agencies. We use your SSN solely for our business of providing insurance services and never disclose information in an unauthorized way. Capstone uses industry standards of security to safeguard your information. Your SSN is used for insurance rating purposes only and does not affect your credit score.

SSN



Many of our insurance carriers use a credit and claims based proprietary model to generate an insurance score for rating. While you are not required to provide your SSN during the quoting stage, the use of your SSN assures accurate rating and helps us gather additional information from consumer reporting agencies. We use your SSN solely for our business of providing insurance services and never disclose information in an unauthorized way. Capstone uses industry standards of security to safeguard your information. Your SSN is used for insurance rating purposes only and does not affect your credit score.

123-12-1234

Marital Status

Age 1st Licensed

Highest Level of Education

Away at School?

If yes, please explain

+ Add Another Driver

- Remove Last Driver

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Accidents or Tickets

Please list all accidents or tickets in the last 3-5 years.

Driver's Name

First

Middle

Last

Suffix

Date of Accident or Ticket

Description

Amount Paid

+ Add Another Accident or Ticket

- Remove Last Accident or Ticket

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Commercial Information

Proposed Effective Date

Name Insured

Your Business's Name

Many of our insurance carriers use a credit and claims based proprietary model to generate an insurance score for rating. While you are not required to provide your SSN during the quoting stage, the use of your SSN assures accurate rating and helps us gather additional information from consumer reporting agencies. We use your SSN solely for our business of providing insurance services and never disclose information in an unauthorized way. Capstone uses industry standards of security to safeguard your information. Your SSN is used for insurance rating purposes only and does not affect your credit score.

FEIN or SSN



Many of our insurance carriers use a credit and claims based proprietary model to generate an insurance score for rating. While you are not required to provide your SSN during the quoting stage, the use of your SSN assures accurate rating and helps us gather additional information from consumer reporting agencies. We use your SSN solely for our business of providing insurance services and never disclose information in an unauthorized way. Capstone uses industry standards of security to safeguard your information. Your SSN is used for insurance rating purposes only and does not affect your credit score.

12-1234567 or 123-12-1234

Business Phone

Business Mailing Address

Street, Apt/STE

City

State

Zip Code

Business Website

Business Type

DBA Name

Contact Name

Primary Phone

Primary Email

Premise Location

Street, Apt/STE

City

State

Zip Code

# Full-Time Employees

# Part-Time Employees

Annual Revenues

Any area leased to others?

Interest

Date Business Started

Nature of Business

Description of Primary Operations

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Prior Carrier Information

Carrier

Policy Number

Premium

Effective Date

Expiration Date

Time with Carrier

Loss History

Enter all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the last 5 years.

Date Of Occurrence

Date Of Claim

Amount Paid

Claim Open?

Type/Description of Occurrence or Claim

+ Add Another Claim or Loss

- Remove Last Claim or Loss

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Life Information

Name *

First

Middle

Last

Phone Number *

Email *

Date of Birth

Health

Do you use tobacco in any form?

Requested Amount

Policy Type

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Interested in Other Lines of Insurance

I am interested in obtaining insurance proposals on the following lines of insurance:

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Would you like to bundle an additional policy?

No thank you, I do not want to bundle any more insurance.

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Final Step

How did you hear about us?

Were you referred to or are you currently working with a Capstone agent?

Permission to Obtain Insurance Score *



Many of our insurance carriers use a credit and claims based proprietary model to generate an insurance score for rating. While you are not required to provide your SSN during the quoting stage, the use of your SSN assures accurate rating and helps us gather additional information from consumer reporting agencies. We use your SSN solely for our business of providing insurance services and never disclose information in an unauthorized way. Capstone uses industry standards of security to safeguard your information. Your SSN is used for insurance rating purposes only and does not affect your credit score.

Permission to Obtain Insurance Score

Acknowledge Privacy and Terms of Site *

I agree to the provided terms.

Additional Info

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this is too much, let's talk!

Homeowners

Flood

auto

commercial

life

Other products

Please select the type of insurance you need.

Personal Information

Residence Information

Structure Details

Roof Details

Utility Details

Final Homeowner Details

Flood Information

Coverages & Limits

Vehicle Information

Driver Information

Accidents or Tickets

Commercial Information

Prior Carrier Information

Loss History

Life Information

Interested in Other Lines of Insurance

Would you like to bundle an additional policy?

Final Step