Farquhar & Gill Quote Request
Thank you for giving us this opportunity to work with you on a quote for your insurance needs. Please provide us with the following information so that we can prepare an accurate, customized proposal for your review.
What type(s) of coverage would you like for us to quote?
Homeowners
Auto
Landlords
Renters
Personal Umbrella (PUP)
Scheduled Articles
Motorcycle
Boat/ATV
RV/Trailer/Camper
Life Insurance
Commercial/Business
Other
Primary Insured | First Name
Primary Insured | Last Name
Primary Insured | Date of Birth
Primary Insured | Drivers License Number
Primary Insured | Mobile Phone
Primary Insured | Email
Primary Insured | Sex
Select One
Male
Female
Primary Insured | Employment
Select One
Employed
Self-Employed
Retired
Student
Other
Primary Insured | Occupation
Primary Insured | Education
Select highest level
High School / GED
Some College
Associates
Bachelors
Masters
PhD
Other
Primary Insured | Marital Status
Select One
Single
Married/Engaged
Divorced
Widowed
Other
Current Address
How Long?
Previous Address (if less than 3 years)
Address to be Insured (if different than current)
Age of Roof?
Current Insurance Carrier? (If no Current Carrier, state "None")
How Long with Current Insurance Carrier?
Any claims in the past five (5) years? (Check all that apply)
Auto Claim
Homeowners or Property Claim
Other
None
Claim Details (Please provide a brief description)
Additional Insured
Please provide the information requested below for a spouse or any party that is considered an additional named insured.
Additional Insured | First Name
Additional Insured | Last Name
Additional Insured | Date of Birth
Additional Insured | Drivers License Number
Additional Insured | Mobile Phone
Additional Insured | Email
Additonal Insured | Sex
Select One
Male
Female
Additional Insured | Employment
Select One
Employed
Self-Employed
Retired
Student
Other
Additional Insured | Occupation
Additional Insured | Education
Select highest level
High School / GED
Some College
Associates
Bachelors
Masters
PhD
Other
Additional Insured | Marital Status
Select One
Single
Married/Engaged
Divorced
Widowed
Other
Additional Information
Please provide the information requested below regarding young/additional drivers and vehicle information needed to produce an accurate proposal. If you are able to upload declaration pages/coverage summaries that include this information - please skip down to the Helpful Documents section.
Other Drivers to be Insured? (Please provide Name, Date of Birth and Drivers License Number for each driver.)
Vehicles to be Insured? (Please provide Year, Make, Model & VIN)
Helpful Documents
Please send us your current declaration pages and/or coverage summaries so that we are able to match your eligible discounts and preferred coverage limits. Images and/or pictures of documents can be texted directly to our agency at 918-238-8540 or emailed to us at contactus@farquhargill.com.
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