Account Owner Information

First Name *

Last Name *

Date of birth *

Account Owner Gender

Account Owner Gender

Male
Female
Prefer Not To Say
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Phone *

Email *

Address *

City *

State *

Postal code *

Marital Status *

Married

Widowed

Single

Spouse's First Name *

Spouse's Last Name *

Spouse DOB *

Spouse Gender

Spouse Gender

Male
Female
Prefer Not To Say
No elements found. Consider changing the search query.
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Account Owner Information

Proof of Residency *

Acceptable: Utility bill (e.g., water, electric, gas, Internet, trash). Unacceptable: Cell phone.

Proof of Ownership *

Copy of deed or title, paid property tax receipt, or home purchase contract. For Renters Quotes just upload any empty file

Account Owner Drivers License *

Picture of valid drivers license is required

Additional Drivers in Household? *

Additional Drivers in Household?

Yes
No
No elements found. Consider changing the search query.
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Driver #2 Information

Driver #2 Full Name

Driver #2 Birthdate

Driver #2 Drivers License *

Picture of valid drivers license is required

How is Driver #2 related to the account owner? *

Is Driver #2 a full-time student? *

Yes, with a 3.0 or higher GPA

Yes, Full time Student (12 credit hours or more)

No, not a full time student

Add 3rd Driver to household? *

Add 3rd Driver to household?

Yes, there are more drivers in our household
Nope, that's all the drivers!
No elements found. Consider changing the search query.
List is empty.

Driver #3 Information

Driver #3 Full Name

Driver #3 Birthdate

Driver #3 Drivers License *

Picture of valid drivers license is required

How is Driver #3 related to the account owner?

Is Driver #3 a full-time student?

Is Driver #3 a full-time student?

Yes, with a 3.0 or higher GPA
Yes, Full time Student with 2.9 GPA or lower
No, not a full time student
No elements found. Consider changing the search query.
List is empty.

Add 4th Driver to household?

Add 4th Driver to household?

Yes, there are more drivers in our household
Nope, that's all the drivers!
No elements found. Consider changing the search query.
List is empty.

Driver #4 Information

Driver #4 Name

Driver #4 Birthdate

Driver #4 Drivers License *

Picture of valid drivers license required

How is Driver #4 related to the account owner? *

Is Driver #4 a full-time student?

Is Driver #4 a full-time student?

Yes, with a 3.0 or higher GPA
Yes, with a 2.9 or lower GPA
No, not a full time student
No elements found. Consider changing the search query.
List is empty.

Add 5th Driver to household?

Add 5th Driver to household?

Yes, there are more drivers in our household
Nope, that's all the drivers!
No elements found. Consider changing the search query.
List is empty.

Driver #5 Information

Driver #5 Full Name

Driver #5 Birthdate

Driver #5 Drivers License *

Picture of valid drivers license required

How is Driver #5 related to the account owner?

Is Driver #5 a full-time student?

Is Driver #5 a full-time student?

Yes, with a 3.0 or higher GPA
Yes, with a 2.9 or lower GPA
No, not a full time student
No elements found. Consider changing the search query.
List is empty.

Are there any additional drivers?

Yes

No

Please include all additional drivers info on this screen

Additional File Upload

Pictures of any additional drivers license numbers

Good Student Documents

In order to have the good student discount placed we will need the most recent grade report showing GPA, Student Name, and Date

Vehicle #1 Year *

Vehicle #1 Make *

Vehicle #1 Model *

Vehicle #1 Registration *

Required for all vehicles insured

Vehicle #1 Odometer *

Required for all vehicles insured

Vehicle #1 Photos (file) *

4 Photos Required (EACH SIDE)

Do you have other vehicles? *

Yes

No

Vehicle #2 Year *

Vehicle #2 Make *

Vehicle #2 Model *

Vehicle #2 Registration *

Required for all vehicles insured

Vehicle #2 Odometer *

Required for all vehicles insured

Vehicle photos of all 4 sides

4 PHOTOS (1 of each side)

Do you have other vehicles? *

Yes

No

Vehicle #3 Year *

Vehicle #3 Make *

Vehicle #3 Model *

Vehicle #3 Registration *

Required for all vehicles insured

Vehicle #3 Odometer *

Required for all vehicles insured

Vehicle photo of all 4 sides

4 PHOTOS (1 of each side)

Do you have other vehicles? *

Yes

No

Vehicle #4 Year *

Vehicle #4 Make *

Vehicle #4 Model *

Vehicle #4 Registration *

Required for all vehicles insured

Vehicle #4 Odometer *

Required for all vehicles insured

Vehicle photo of all 4 sides-vehicle4

4 Photos (1 of each side)

Do you have other vehicles? *

Yes

No

Vehicle #5 Year *

Vehicle #5 Make *

Vehicle #5 Model *

Vehicle #5 Registration *

Required for all vehicles insured

Vehicle #5 Odometer *

Required for all vehicles insured

Vehicle photo of all 4 sides-vehicle5

4 PHOTOS (1 of each side)

Do you have Any Additional Vehicles? *

Yes

No

Additional Vehicles?

Home Information

Do you Own or Rent your home? *

Own

Rent

Rental Information

If less than 5 years ago, what was your previous Address?

How much contents coverage do you require? *

How much content coverage do you require?

$25,000
$50,000
$75,000
$100,000
$100,000+
No elements found. Consider changing the search query.
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Do you need more than 300k worth of liability coverage? *

Do you need more than 300k worth of liability coverage?

Yes
No
No elements found. Consider changing the search query.
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Do you have dogs? *

Yes

No

Home Information

Year Built

If you moved in less than 5 years ago, what was your previous Address?

What is the sq. ft.?

What kind of flooring?

Choose all that applies

Concrete
Carpet
Tile
Laminate
Wood
Vinyl
No elements found. Consider changing the search query.
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What kind of roof?

What kind of roof?

Concrete tile
Asphalt shingles
Metal roof
Rubber roof - flat
Tar and gravel - flat
No elements found. Consider changing the search query.
List is empty.

Is there a fireplace?

Yes

No

How many cars can fit the garage?

Number of bathrooms?

1

1.5

2

2.5

3

3.5

4 and more

Home Information

Bath 1 Finish

Builders

Semi-custom

Full custom

Home Information

Bath 1 Finish

Builder's

Semi-custom

Full Custom

Bath 2 Finish

Builders

Semi-custom

Full custom

Home Information

Bath 1 Finish

Builder's

Semi-custom

Full Custom

Bath 2 Finish

Builders

Semi-custom

Full custom

Bath 3 Finish

Builders

Semi-custom

Full custom

Home Information

Bath 1 Finish

Builder's

Semi-custom

Full Custom

Bath 2 Finish

Builders

Semi-custom

Full custom

Bath 3 Finish

Builders

Semi-custom

Full custom

Bath 4 Finish

Builders

Semi-custom

Full custom

Bathroom Photos

Bath #1 Photo *

*** Required ***

Bath #2 Photo

Required (if applicable)

Bath #3 Photo

Required (if applicable)

Bath #4 Photo

Required (if applicable)

Other Required Home Photos

Inside Home Photos (include Kitchen, bedrooms, greatrooms

ATTACH MULTIPLE PHOTOS OF ALL ROOMS

Exterior photos (4 outside phots of home of each side)

Showing all four sides and as much of the roof as possible in four photos.

Electrical Panel (photo)

Water Heater (photo)

Furnace (photo)

Home Information

Alarm Type

Choose all that apply

No alarm
Video doorbell
Local alarm - not monitored
Local Alarm with Monitoring subscription
No elements found. Consider changing the search query.
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Do you live in a gated community?

Yes

No

Gated Community Name? (If Applicable)

Do you have dogs? *

Yes

No

Pet Dog Information

Name *

Weight *

Age *

Color *

Ever had a dog bite claim? *

Yes

No

Dog Photo (file) *

Dog Photo (file)

Do you currently have an umbrella policy?

Do you currently have an umbrella policy?

Yes
No
No elements found. Consider changing the search query.
List is empty.

Do you own a business?

Yes

No

Do you have any existing life insurance or annuity needs?

Yes

No

Upload dec pages for other policies you want us to take a look at

Declaration Page Upload

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Office: 6383 Nancy Ridge Dr San Diego, CA 92121

Call 858-492-0537

Email: Brandon@shefflerinsuranceservices.com

Site: www.Shefflerinsuranceservices.com