new.eztrack.xyz
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66.33.209.127
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Submitted URL: https://www.new.eztrack.xyz/
Effective URL: https://new.eztrack.xyz/
Submission: On September 21 via automatic, source certstream-suspicious — Scanned from DE
Effective URL: https://new.eztrack.xyz/
Submission: On September 21 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 1 forms found in the DOM
POST
<form method="post" action="">
<div class="input_pad toggleClick">
<div class="toggle btn btn-danger off btn-xs ios" data-toggle="toggle" style="width: 46.8594px; height: 18.5938px;"><input type="checkbox" data-toggle="toggle" data-on="YES" data-off="No" data-onstyle="success" data-offstyle="danger"
data-size="xs" id="homeownersCheck" name="homeownersCheck" data-style="ios">
<div class="toggle-group"><label class="btn btn-success btn-xs toggle-on">YES</label><label class="btn btn-danger btn-xs toggle-off">No</label><span class="toggle-handle btn btn-light btn-xs"></span></div>
</div>
<label for="homeownersCheck">Home?</label>
</div>
<div class="input_pad toggleClick">
<div class="toggle btn btn-danger off btn-xs ios" data-toggle="toggle" style="width: 46.8594px; height: 18.5938px;"><input type="checkbox" data-toggle="toggle" data-on="YES" data-off="No" data-onstyle="success" data-offstyle="danger"
data-size="xs" id="renterCheck" name="renterCheck" data-style="ios">
<div class="toggle-group"><label class="btn btn-success btn-xs toggle-on">YES</label><label class="btn btn-danger btn-xs toggle-off">No</label><span class="toggle-handle btn btn-light btn-xs"></span></div>
</div>
<label for="renterCheck">Rental property?</label>
</div>
<div class="input_pad toggleClick">
<div class="toggle btn btn-danger off btn-xs ios" data-toggle="toggle" style="width: 46.8594px; height: 18.5938px;"><input type="checkbox" data-toggle="toggle" data-on="YES" data-off="No" data-onstyle="success" data-offstyle="danger"
data-size="xs" id="autoCheck" name="auto" data-style="ios">
<div class="toggle-group"><label class="btn btn-success btn-xs toggle-on">YES</label><label class="btn btn-danger btn-xs toggle-off">No</label><span class="toggle-handle btn btn-light btn-xs"></span></div>
</div>
<label for="autoCheck">Car?</label>
</div>
<div class="input_pad toggleClick">
<div class="toggle btn btn-danger off btn-xs ios" data-toggle="toggle" style="width: 46.8594px; height: 18.5938px;"><input type="checkbox" data-toggle="toggle" data-on="YES" data-off="No" data-onstyle="success" data-offstyle="danger"
data-size="xs" id="motoCheck" name="motorcycle" data-style="ios">
<div class="toggle-group"><label class="btn btn-success btn-xs toggle-on">YES</label><label class="btn btn-danger btn-xs toggle-off">No</label><span class="toggle-handle btn btn-light btn-xs"></span></div>
</div>
<label for="motoCheck">Motorcycle?</label>
</div>
<div class="input_pad toggleClick">
<div class="toggle btn btn-danger off btn-xs ios" data-toggle="toggle" style="width: 46.8594px; height: 18.5938px;"><input type="checkbox" data-toggle="toggle" data-on="YES" data-off="No" data-onstyle="success" data-offstyle="danger"
data-size="xs" id="RVCheck" name="RVCheck" data-style="ios">
<div class="toggle-group"><label class="btn btn-success btn-xs toggle-on">YES</label><label class="btn btn-danger btn-xs toggle-off">No</label><span class="toggle-handle btn btn-light btn-xs"></span></div>
</div>
<label for="RVCheck">Recreational vehicle (RV)?</label>
</div>
<div id="general_block">
<h3>General Information:</h3>
<div class="form-group row">
<label for="form_name_birthday" class="col-4 col-form-label">Name & Birthdates of all household members</label>
<div class="col-8">
<textarea id="form_name_birthday" name="form_name_birthday" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_home_address" class="col-4 col-form-label">Home Address</label>
<div class="col-8">
<input id="form_home_address" name="form_home_address" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_mailing_address" class="col-4 col-form-label">Mailing Address, if different</label>
<div class="col-8">
<input id="form_mailing_address" name="form_mailing_address" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_ssn" class="col-4 col-form-label">Social Security Number</label>
<div class="col-8">
<input id="form_ssn" name="form_ssn" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_education" class="col-4 col-form-label">Highest Level of Education (you & spouse)</label>
<div class="col-8">
<input id="form_education" name="form_education" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_occupation" class="col-4 col-form-label">Occupation (you & spouse)</label>
<div class="col-8">
<input id="form_occupation" name="form_occupation" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_felony" class="col-4 col-form-label">Any convictions of a felony?</label>
<div class="col-8">
<select id="form_felony" class="custom-select">
<option selected="" value=" "></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
</div>
</div>
<div id="homeowners_block" class="initial_hide">
<h3>Homeowners Information:</h3>
<div class="form-group row">
<label for="form_home_date" class="col-4 col-form-label">Effective Date of Current Policy</label>
<div class="col-8">
<input id="form_home_date" name="form_home_date" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_home_years" class="col-4 col-form-label">Number of Years at Current Address</label>
<div class="col-8">
<input id="form_home_years" name="form_home_years" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_home_prior_address" class="col-4 col-form-label">If less than 5 years, please provide prior address</label>
<div class="col-8">
<input id="form_home_prior_address" name="form_home_prior_address" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_home_nonfamily" class="col-4 col-form-label">Any residents not current family members?</label>
<div class="col-8">
<input id="form_home_nonfamily" name="form_home_nonfamily" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_home_children_num" class="col-4 col-form-label">Number of children in home</label>
<div class="col-8">
<input id="form_home_children_num" name="form_home_children_num" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_home_acres" class="col-4 col-form-label">Number of acres if not in a neighborhood</label>
<div class="col-8">
<input id="form_home_acres" name="form_home_acres" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_home_dogs" class="col-4 col-form-label">Any dogs in the home?</label>
<div class="col-8">
<input id="form_home_dogs" name="form_home_dogs" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_home_dog_detail" class="col-4 col-form-label">If yes, list number and breed(s).</label>
<div class="col-8">
<input id="form_home_dog_detail" name="form_home_dog_detail" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label class="col-4">House features:</label>
<div class="col-8">
<div class="custom-control custom-checkbox custom-control-inline">
<input name="form_home_features" id="form_home_features_0" type="checkbox" class="custom-control-input" value="swimming">
<label for="form_home_features_0" class="custom-control-label">Swimming Pool</label>
</div>
<div class="custom-control custom-checkbox custom-control-inline">
<input name="form_home_features" id="form_home_features_1" type="checkbox" class="custom-control-input" value="trampoline">
<label for="form_home_features_1" class="custom-control-label">Trampoline</label>
</div>
<div class="custom-control custom-checkbox custom-control-inline">
<input name="form_home_features" id="form_home_features_2" type="checkbox" class="custom-control-input" value="fire_alarm">
<label for="form_home_features_2" class="custom-control-label">Central Fire and/or Burglar Alarm</label>
</div>
</div>
</div>
<div class="form-group row">
<label for="form_home_construction" class="col-4 col-form-label">Any current construction or renovation?</label>
<div class="col-8">
<input id="form_home_construction" name="form_home_construction" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_home_losses" class="col-4 col-form-label">Please describe any losses during the past 5 years.</label>
<div class="col-8">
<textarea id="form_home_losses" name="form_home_losses" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_home_roof" class="col-4 col-form-label">Roof - Most recent replacement year</label>
<div class="col-8">
<input id="form_home_roof" name="form_home_roof" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_home_plumbing" class="col-4 col-form-label">Plumbing - Most recent replacement year</label>
<div class="col-8">
<input id="form_home_plumbing" name="form_home_plumbing" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_home_electrical" class="col-4 col-form-label">Electrical - Most recent replacement year</label>
<div class="col-8">
<input id="form_home_electrical" name="form_home_electrical" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_home_hvac" class="col-4 col-form-label">HVAC - Most recent replacement year</label>
<div class="col-8">
<input id="form_home_hvac" name="form_home_hvac" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_home_mortgage_info" class="col-4 col-form-label">Mortgage Information</label>
<div class="col-8">
<input id="form_home_mortgage_info" name="form_home_mortgage_info" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_home_prem" class="col-4 col-form-label">Current Homeowners Insurance Premium (estimated)</label>
<div class="col-8">
<input id="form_home_prem" name="form_home_prem" type="text" class="form-control">
</div>
</div>
</div>
<div id="renter_block" class="initial_hide">
<h3>Rental Property Information:</h3>
<div class="form-group row">
<label for="form_rental_date" class="col-4 col-form-label">Effective Date of Current Policy</label>
<div class="col-8">
<input id="form_rental_date" name="form_rental_date" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_rental_address" class="col-4 col-form-label">Rental Property Address</label>
<div class="col-8">
<input id="form_rental_address" name="form_rental_address" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_rental_tenant" class="col-4 col-form-label">Currently Tenant Occupied</label>
<div class="col-8">
<select id="form_rental_tenant" class="custom-select">
<option selected="" value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
</div>
<div class="form-group row">
<label for="form_rental_lease_term" class="col-4 col-form-label">Term of lease (monthly, annually)</label>
<div class="col-8">
<input id="form_rental_lease_term" name="form_rental_lease_term" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_rental_strent" class="col-4 col-form-label">Any participation in short term rentals (Airbnb)</label>
<div class="col-8">
<select id="form_rental_strent" class="custom-select">
<option selected="" value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
</div>
<div class="form-group row">
<label for="form_rental_tenant_dog" class="col-4 col-form-label">Any dogs kept by tenant</label>
<div class="col-8">
<select id="form_rental_tenant_dog" class="custom-select">
<option selected="" value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
</div>
<div class="form-group row">
<label for="form_rental_dog_tenant" class="col-4 col-form-label">If yes, list number and breed(s).</label>
<div class="col-8">
<input id="form_rental_dog_tenant" name="form_rental_dog_tenant" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_rental_tenant_fire" class="col-4 col-form-label">Central Fire and/or Burglar Alarm</label>
<div class="col-8">
<select id="form_rental_tenant_fire" class="custom-select">
<option selected="" value=""></option>
<option value="None">None</option>
<option value="fire">Central Fire</option>
<option value="burglar">Burglar Alarm</option>
<option value="both">Both</option>
</select>
</div>
</div>
<div class="form-group row">
<label for="form_rental_construction" class="col-4 col-form-label">Any current construction or renovation?</label>
<div class="col-8">
<input id="form_rental_construction" name="form_rental_construction" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_rental_losses" class="col-4 col-form-label">Please describe any losses during the past 5 years.</label>
<div class="col-8">
<textarea id="form_rental_losses" name="form_rental_losses" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_rental_roof" class="col-4 col-form-label">Roof - Most recent replacement year</label>
<div class="col-8">
<input id="form_rental_roof" name="form_rental_roof" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_rental_plumbing" class="col-4 col-form-label">Plumbing - Most recent replacement year</label>
<div class="col-8">
<input id="form_rental_plumbing" name="form_rental_plumbing" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_rental_electrical" class="col-4 col-form-label">Electrical - Most recent replacement year</label>
<div class="col-8">
<input id="form_rental_electrical" name="form_rental_electrical" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_rental_hvac" class="col-4 col-form-label">HVAC - Most recent replacement year</label>
<div class="col-8">
<input id="form_rental_hvac" name="form_rental_hvac" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_rental_prem" class="col-4 col-form-label">Current Insurance Premium (estimated)</label>
<div class="col-8">
<input id="form_rental_prem" name="form_rental_prem" type="text" class="form-control">
</div>
</div>
</div>
<div id="auto_block" class="initial_hide">
<h3>Auto Information:</h3>
<div class="form-group row">
<label for="form_auto_date" class="col-4 col-form-label">Current Effective Date of Policy</label>
<div class="col-8">
<input id="form_auto_date" name="form_auto_date" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_auto_policy_len" class="col-4 col-form-label">Is current policy 6 or 12 months?</label>
<div class="col-8">
<input id="form_auto_policy_len" name="form_auto_policy_len" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_auto_liab_limits" class="col-4 col-form-label">Current Liability Limits (eg. $100,000 per person, $300,000 per accident)</label>
<div class="col-8">
<textarea id="form_auto_liab_limits" name="form_auto_liab_limits" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_auto_deductible" class="col-4 col-form-label">Current Comprehensive Deductible Current Collision Deductible</label>
<div class="col-8">
<textarea id="form_auto_deductible" name="form_auto_deductible" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_auto_dl_nums" class="col-4 col-form-label">Driver License Number of All Drivers</label>
<div class="col-8">
<textarea id="form_auto_dl_nums" name="form_auto_dl_nums" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="forms_auto_vins" class="col-4 col-form-label">Vehicle Identification Number of All Vehicles (picture of your current Auto ID Card works)</label>
<div class="col-8">
<textarea id="forms_auto_vins" name="forms_auto_vins" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_auto_acquisition" class="col-4 col-form-label">Indication if each vehicle was bought new or used</label>
<div class="col-8">
<input id="form_auto_acquisition" name="form_auto_acquisition" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_auto_students" class="col-4 col-form-label">Any Student Drivers in the Home?</label>
<div class="col-8">
<input id="form_auto_students" name="form_auto_students" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_auto_gpa" class="col-4 col-form-label">If yes, is their GPA 3.0 or Higher?</label>
<div class="col-8">
<input id="form_auto_gpa" name="form_auto_gpa" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_auto_driversed" class="col-4 col-form-label">Did they attend Drivers Education Program?</label>
<div class="col-8">
<input id="form_auto_driversed" name="form_auto_driversed" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_auto_hundred_miles" class="col-4 col-form-label">Do they go to school over 100 miles away from home address?</label>
<div class="col-8">
<input id="form_auto_hundred_miles" name="form_auto_hundred_miles" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_auto_primary_use" class="col-4 col-form-label">Primary Use for each vehicle? (eg. Pleasure, commuting)</label>
<div class="col-8">
<input id="form_auto_primary_use" name="form_auto_primary_use" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_auto_estimated_miles" class="col-4 col-form-label">Estimated miles driven per year per vehicle</label>
<div class="col-8">
<input id="form_auto_estimated_miles" name="form_auto_estimated_miles" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_auto_ride_sharing" class="col-4 col-form-label">Any driving done for ride sharing services? (eg. UBER, Lyft)</label>
<div class="col-8">
<input id="form_auto_ride_sharing" name="form_auto_ride_sharing" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_auto_moving_vio" class="col-4 col-form-label">Information on any moving violations in last 5 years.</label>
<div class="col-8">
<textarea id="form_auto_moving_vio" name="form_auto_moving_vio" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_auto_accidents" class="col-4 col-form-label">Information on any accidents in last 5 years.</label>
<div class="col-8">
<textarea id="form_auto_accidents" name="form_auto_accidents" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_auto_comp_loss" class="col-4 col-form-label">Information on any comprehensive losses in last 5 years, (eg. Hail)</label>
<div class="col-8">
<textarea id="form_auto_comp_loss" name="form_auto_comp_loss" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_auto_lienholder" class="col-4 col-form-label">Lease or Lienholder Information for each vehicle</label>
<div class="col-8">
<input id="form_auto_lienholder" name="form_auto_lienholder" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_auto_prem" class="col-4 col-form-label">Current Auto Premium (estimated)</label>
<div class="col-8">
<input id="form_auto_prem" name="form_auto_prem" type="text" class="form-control">
</div>
</div>
</div>
<div id="moto_block" class="initial_hide">
<h3>Motocycle Information:</h3>
<div class="form-group row">
<label for="form_moto_date" class="col-4 col-form-label">Current Effective Date of Policy</label>
<div class="col-8">
<input id="form_moto_date" name="form_moto_date" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_moto_policy_len" class="col-4 col-form-label">Is current policy 6 or 12 months?</label>
<div class="col-8">
<input id="form_moto_policy_len" name="form_moto_policy_len" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_moto_liab_limits" class="col-4 col-form-label">Current Liability Limits (eg. $100,000 per person, $300,000 per accident)</label>
<div class="col-8">
<textarea id="form_moto_liab_limits" name="form_moto_liab_limits" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_moto_dl_nums" class="col-4 col-form-label">Driver License Number of All Drivers</label>
<div class="col-8">
<textarea id="form_moto_dl_nums" name="form_moto_dl_nums" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="forms_moto_vins" class="col-4 col-form-label">Vehicle Identification Number of All Vehicles (picture of your current Auto ID Card works)</label>
<div class="col-8">
<textarea id="forms_moto_vins" name="forms_moto_vins" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_moto_aftermarket" class="col-4 col-form-label">Any after factory equipment installed? If Yes, estimated value.</label>
<div class="col-8">
<input id="form_moto_aftermarket" name="form_moto_aftermarket" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_moto_event" class="col-4 col-form-label">Do you partake in special processions in connection with your business? (e.g. parades, funerals)</label>
<div class="col-8">
<input id="form_moto_event" name="form_moto_event" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_moto_endorsement" class="col-4 col-form-label">Do you have the motrocycle endorsement on your license?</label>
<div class="col-8">
<select id="form_moto_endorsement" class="custom-select">
<option selected="" value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
</div>
<div class="form-group row">
<label for="form_moto_safety_course" class="col-4 col-form-label">Have you partipcated in a Operators Safety Course and/or Alcohol & Drug Awareness Course in the last 5 years. If so, date completed?</label>
<div class="col-8">
<input id="form_moto_safety_course" name="form_moto_safety_course" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_moto_group" class="col-4 col-form-label">Do you belong in a motorcycle riding group? If so, name of group?</label>
<div class="col-8">
<input id="form_moto_group" name="form_moto_group" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_moto_accidents" class="col-4 col-form-label">Information on any accidents in last 5 years.</label>
<div class="col-8">
<textarea id="form_moto_accidents" name="form_moto_accidents" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_moto_prem" class="col-4 col-form-label">Current Auto Premium (estimated)</label>
<div class="col-8">
<input id="form_moto_prem" name="form_moto_prem" type="text" class="form-control">
</div>
</div>
</div>
<div id="RV_block" class="initial_hide">
<h3>Recreational Vehicle:</h3>
<div class="form-group row">
<label for="form_RV_date" class="col-4 col-form-label">Current Effective Date of Policy</label>
<div class="col-8">
<input id="form_RV_date" name="form_RV_date" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_RV_dl_nums" class="col-4 col-form-label">Driver License Number of All Drivers</label>
<div class="col-8">
<textarea id="form_RV_dl_nums" name="form_RV_dl_nums" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_RV_type" class="col-4 col-form-label">Motorhome or Travel Trailer?</label>
<div class="col-8">
<select id="form_RV_type" class="custom-select">
<option selected=""></option>
<option value="No">Motorhome</option>
<option value="Yes">Travel Trailer</option>
</select>
</div>
</div>
<div class="form-group row">
<label for="form_RV_make" class="col-4 col-form-label">Manufacture, Model, and Model Year</label>
<div class="col-8">
<input id="form_RV_make" name="form_RV_make" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="forms_RV_vins" class="col-4 col-form-label">Vehicle Identification Number of All Vehicles (picture of your current Auto ID Card works)</label>
<div class="col-8">
<textarea id="forms_RV_vins" name="forms_RV_vins" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_RV_length" class="col-4 col-form-label">Length</label>
<div class="col-8">
<input id="form_RV_length" name="form_RV_length" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_RV_purch_date" class="col-4 col-form-label">Estimated Purchase Date</label>
<div class="col-8">
<input id="form_RV_purch_date" name="form_RV_purch_date" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_RV_purch_price" class="col-4 col-form-label">Estimated Purchase Price</label>
<div class="col-8">
<input id="form_RV_purch_price" name="form_RV_purch_price" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_RV_primary" class="col-4 col-form-label">Primary Use</label>
<div class="col-8">
<input id="form_RV_primary" name="form_RV_primary" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_RV_estimated_miles" class="col-4 col-form-label">Estimated miles driven per year per vehicle</label>
<div class="col-8">
<input id="form_RV_estimated_miles" name="form_RV_estimated_miles" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_RV_park" class="col-4 col-form-label">Is RV currently located in a park?</label>
<div class="col-8">
<input id="form_RV_park" name="form_RV_park" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_RV_property_value" class="col-4 col-form-label">Estimated amount of personal property inside RV?</label>
<div class="col-8">
<input id="form_RV_property_value" name="form_RV_property_value" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label for="form_RV_comp_loss" class="col-4 col-form-label">Information on any comprehensive losses in last 5 years, (eg. Hail)</label>
<div class="col-8">
<textarea id="form_RV_comp_loss" name="form_RV_comp_loss" cols="40" rows="5" class="form-control"></textarea>
</div>
</div>
<div class="form-group row">
<label for="form_RV_prem" class="col-4 col-form-label">Current RV Premium (estimated)</label>
<div class="col-8">
<input id="form_RV_prem" name="form_RV_prem" type="text" class="form-control">
</div>
</div>
</div>
<div class="form-group row">
<div class="offset-4 col-8">
<button name="submit" type="submit" class="btn btn-outline-primary btn-lg">Request Quote</button>
</div>
</div>
</form>Text Content
Brightway Insurance, The Lunte Family Agency Thank you for sending your information. We will review and get back to you as quick as we can. Thank you for contacting Brightway Insurance, The Lunte Family Agency. In order to provide you with the most accurate quote possible, please complete the form below. We're here to answer any questions you have along the way. YESNo Home? YESNo Rental property? YESNo Car? YESNo Motorcycle? YESNo Recreational vehicle (RV)? GENERAL INFORMATION: Name & Birthdates of all household members Home Address Mailing Address, if different Social Security Number Highest Level of Education (you & spouse) Occupation (you & spouse) Any convictions of a felony? No Yes HOMEOWNERS INFORMATION: Effective Date of Current Policy Number of Years at Current Address If less than 5 years, please provide prior address Any residents not current family members? Number of children in home Number of acres if not in a neighborhood Any dogs in the home? If yes, list number and breed(s). House features: Swimming Pool Trampoline Central Fire and/or Burglar Alarm Any current construction or renovation? Please describe any losses during the past 5 years. Roof - Most recent replacement year Plumbing - Most recent replacement year Electrical - Most recent replacement year HVAC - Most recent replacement year Mortgage Information Current Homeowners Insurance Premium (estimated) RENTAL PROPERTY INFORMATION: Effective Date of Current Policy Rental Property Address Currently Tenant Occupied No Yes Term of lease (monthly, annually) Any participation in short term rentals (Airbnb) No Yes Any dogs kept by tenant No Yes If yes, list number and breed(s). Central Fire and/or Burglar Alarm None Central Fire Burglar Alarm Both Any current construction or renovation? Please describe any losses during the past 5 years. Roof - Most recent replacement year Plumbing - Most recent replacement year Electrical - Most recent replacement year HVAC - Most recent replacement year Current Insurance Premium (estimated) AUTO INFORMATION: Current Effective Date of Policy Is current policy 6 or 12 months? Current Liability Limits (eg. $100,000 per person, $300,000 per accident) Current Comprehensive Deductible Current Collision Deductible Driver License Number of All Drivers Vehicle Identification Number of All Vehicles (picture of your current Auto ID Card works) Indication if each vehicle was bought new or used Any Student Drivers in the Home? If yes, is their GPA 3.0 or Higher? Did they attend Drivers Education Program? Do they go to school over 100 miles away from home address? Primary Use for each vehicle? (eg. Pleasure, commuting) Estimated miles driven per year per vehicle Any driving done for ride sharing services? (eg. UBER, Lyft) Information on any moving violations in last 5 years. Information on any accidents in last 5 years. Information on any comprehensive losses in last 5 years, (eg. Hail) Lease or Lienholder Information for each vehicle Current Auto Premium (estimated) MOTOCYCLE INFORMATION: Current Effective Date of Policy Is current policy 6 or 12 months? Current Liability Limits (eg. $100,000 per person, $300,000 per accident) Driver License Number of All Drivers Vehicle Identification Number of All Vehicles (picture of your current Auto ID Card works) Any after factory equipment installed? If Yes, estimated value. Do you partake in special processions in connection with your business? (e.g. parades, funerals) Do you have the motrocycle endorsement on your license? No Yes Have you partipcated in a Operators Safety Course and/or Alcohol & Drug Awareness Course in the last 5 years. If so, date completed? Do you belong in a motorcycle riding group? If so, name of group? Information on any accidents in last 5 years. Current Auto Premium (estimated) RECREATIONAL VEHICLE: Current Effective Date of Policy Driver License Number of All Drivers Motorhome or Travel Trailer? Motorhome Travel Trailer Manufacture, Model, and Model Year Vehicle Identification Number of All Vehicles (picture of your current Auto ID Card works) Length Estimated Purchase Date Estimated Purchase Price Primary Use Estimated miles driven per year per vehicle Is RV currently located in a park? Estimated amount of personal property inside RV? Information on any comprehensive losses in last 5 years, (eg. Hail) Current RV Premium (estimated) Request Quote Call us: 214-453-1262 Visit us: 2901 W FM 544, Suite 160, Wylie, TX 75098 Loading secure connection...