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Client Profile (Home & Auto)


First of all, thank you!  We want to make sure that your insurance experience is as easy and convenient as possible.  We have a team approach to working with our clients and believe strongly in the importance of the relationship.  Representing multiple insurance carriers, we are able to do the "shopping" for you to find the option that best fits your needs.

If you would rather provide this information to us over the phone, we always welcome a call during our business hours (Mon-Fri, excluding holidays) 8:00 am - 4:00 pm, or after hours by appointment.

Y
ou can also email your current insurance policy to Team@EaglePointIns.com and we can take a look at that to get started.

We will contact you within 24 business hours of receiving your information.

Thank you again and we look forward to working with you!



Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Date of Birth
Required
/ /
Gender
Required
Marital Status
Required
How did you hear about us?
Optional
Current Insurance Provider
Optional
Do you rent or own your home?
Optional
Do you rent or own your home?
Optional
Date of Original Purchase
Optional
/ /
Prior address if you have resided at the current address for less than 2 years.
Optional
Closing Date (if applicable)
Optional
/ /
Year Built
Optional
Style of Home
Optional
Finished Square Feet
Optional
Siding Type
Optional



Age of Roof
Optional
Age of Furnace
Optional
Fireplace(s)
Optional
Type of Basement
Optional
Garage
Optional
Number of Garage Stalls
Optional



Number of Garage Stalls
Optional



Swimming Pool
Optional
Pool
Required
Trampoline
Optional
Dogs
Required
Have you had any home losses/claims in the past 3 years?
Optional
Name of Driver (First, Last)
Required
Gender
Optional
Date of Birth
Required
/ /
License Number
Required
E-Mail Address
Required
Occupation
Optional
Does this driver have any major violations (5yrs), accidents or minor violations (3yrs), comprehensive or collision claims (3yrs)?
Required
Name (First, Last)
Optional
Gender
Required
Date of Birth
Optional
/ /
License Number
Required
Does this driver have any major violations (5yrs), accidents or minor violations (3yrs), comprehensive or collision claims (3yrs)?
Required
Name (First, Last)
Required
Gender
Optional
Date of Birth
Optional
/ /
License Number
Required
Date of Birth
Required
/ /
Does this driver have any major violations (5yrs), accidents or minor violations (3yrs), comprehensive or collision claims (3yrs)?
Required
Vehicle Information
Optional
Vehicle #1
Optional


Vehicle #1
Optional


Vehicle 1 Year Model
Required
Vehicle 1 Make
Required
Vehicle 1 Model
Required
Vehicle 1 VIN
Optional
Vehicle 1 - Average Commute in Miles
Optional
Vehicle #2
Optional


Vehicle #2
Optional


Vehicle 2 Year Model
Required
Vehicle 2 Make
Required
Vehicle 2 Model
Required
Vehicle 2 VIN
Optional
Vehicle 2 - Average Commute in Miles
Optional
Vehicle #3
Optional


Vehicle #3
Optional


Vehicle 3 Year Model
Required
Vehicle 3 Make
Optional
Vehicle 3 Model
Required
Vehicle 3 VIN
Optional
Vehicle #4
Optional


Vehicle #4
Optional


Vehicle 4 Year Model
Required
Vehicle 4 Make
Optional
Vehicle 4 Model
Required
Vehicle 4 VIN
Optional
Do you currently have umbrella insurance coverage?
Optional
Motorcycle Information
Watercraft Information
Recreational Vehicle
Optional
Snowmobile, ATV, etc.
Optional
Additional Comments
Optional
Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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