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Gregory Brown Agency Quick Quote Form
Please fill out this form and we will get back with you as soon as we can. There are some fields that are required. (ie....for auto quotes we need the VIN#) But if your quote doesn't include something required by the form just put N/A. If you have any questions at all, you can text/call to 405.227.5517 or email is greg@browninsuranceokc.com. Thank you!
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* Indicates required question
First and Last Name
for All Drivers in Home
*
Your answer
Date of Birth
for ALL Drivers in Home
*
Your answer
Drivers License #
for
EACH
Driver in Home (Please also include
State the DL is issued
in)
*
Your answer
Phone Number
*
Your answer
Email
Your answer
Address
*
Your answer
How Long Have You Lived at Your Current Address
*
New Purchase
1-4 Years
5+ Years
If you Selected New Purchase or 1-4 Years, Please Provide
Previous Address
You Lived At
*
Your answer
What would you like a quote for?
Auto Insurance
Home Insurance
Renters Insurance
Condo Insurance
Specialty - RV, Boat, ATV, etc
Life Insurance
Business Insurance
Landlord Protector (Rental Property)
Health Insurance
Umbrella
Other:
If you checked AUTO, please input the
VIN #
for
EACH
vehicle.
*
Your answer
This Field is only used if you have additional autos that did not fit on the previous Field.
*
Your answer
For Your Auto Insurance, Please Check the Boxes for Your
Current Bodily Injury and Property Damage Liability Limits
(example - $25,000/$50,000/$25,000 would be 25/50/25)
*
25/50/25
50/100/50
100/300/100
250/500/250
500/500/500
NOT SURE
Other:
Required
For Your Auto Insurance, do you carry
COLLISION
coverage?
*
Yes - $500 Deductible
Yes - $1000 Deductible
No
NOT SURE
Required
For Your Auto Insurance, do you carry
COMPREHENSIVE
coverage? (Comprehensive covers things out of your control, ie....hail, fire, hitting an animal)
*
Yes - $500 Deductible
Yes - $1000 Deductible
No
NOT SURE
Required
For Your Auto Insurance, please check boxes for all additional coverages you currently have or would have interest in
*
Uninusured Motorist Liability
Medical Payments
Rental Car Reimbursement
Towing and Roadside Coverage
NOT SURE
Required
If you checked HOME, what is the year your roof was replaced?
*
Your answer
Please Check the Box for
EACH
Category that Applies to You
Class 3 or Class 4 Hail Resistive Roof
Burglar and/or Fire Alarm that reports to a Company (ADT, Vivint, etc)
Water Sensors in Home
Swimming Pool
Gated Community
Neighborhood Has HOA
Own Trampoline
If Rental Property or Secondary Home Please Provide Address(s) for that Property or Properties
*
Your answer
Any ADDITIONAL Information you would like to add. (ie...one vehicle is liability only or all vehicles liability only, etc)
*
Your answer
Are You Currently or Were You Ever a Member of the Military
*
Yes
No
For
Each
Member of the Household Please Provide
Name of Current Employer
and Your
Job Title
or if you are
Retired or Currently Not Working
*
Your answer
Please Provide
Name of Current Insurance Carrier
and
Expiration Date
of Current Policy or Policies
*
Your answer
How Would You Prefer to Communicate
*
Phone Call
Text
Email
How Did You Hear About Us?
Referral
Radio Advertising
Website
Google/Online Search
Magazine Ad
Other:
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