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About You

Let's gather some initial info before we talk about insurance...

Name*

First Last

Date of Birth*

MM slash DD slash YYYY

How did you hear about us?*

Referred by someone

Google / Online Search

Social Media

I was contacted by the agency

Other

GREAT....we LOVE referrals! Who referred you to us?*

Can you provide some details for us?*

Were you referred to a specific member of Team Barfield?*

Yes

Which team member were you referred to?*

About You

Let's gather some initial info before we talk about insurance...

Email Address*

Mobile Phone*

Is it ok if we text you?*

Yes, texting makes things quick & easy!

No, I don't like texting.

What is your current home address?*

Street Address City State ZIP Code

Have you moved within the past five years?

Yes

What was your previous address?

Street Address City State ZIP Code

Why are you looking for new insurance?*

New Purchase

Unhappy with service from my current agent/company

Unhappy with current price

Unhappy with current coverage

Other

About You

Let's gather some initial info before we talk about insurance...

What is your relationship status?*

Single

Married

Domestic Partner

Spouse's Information

Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Email Address

Mobile Phone

Permission to text?

Yes, texting makes things quick & easy!

No, I don't like texting.

Domestic Partner's Information

Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Email Address

Mobile Phone

Permission to text?

Yes

And now on to the fun stuff...

What kind of insurance proposal can we prepare for you today?*

Auto

Home

Flood

Renters

Landlord Dwelling

Mobile/Manufactured Home

Motorcycle/ATV

Motorhome/Camper

Boat/Watercraft

Personal Liability Umbrella

Life Insurance

Other

Select all that apply

Have you been non-renewed by an insurance provider?*

Yes

Please tell us when and why you were non-renewed.*

Auto Insurance

When would you like your new auto insurance policy to start?*

MM slash DD slash YYYY

Auto Insurance

Your Driver's License Number:*

Your Driver's License State:*

Your Occupation

Your Education Level

Spouse's Driver's License Number:*

Spouse's Driver's License State:*

Spouse's Occupation

Spouse's Education Level

Domestic Partner's Driver's License Number:*

Domestic Partner's Driver's License State:*

Are there additional drivers in your household?*

Yes

Additional Household Drivers:*

Driver Name

Relationship

Date of Birth

DL Number

DL State

Occupation

Education Level

Do any household drivers qualify for a Good Student Discount?*

Yes

Please upload current grade transcripts:

Max. file size: 100 MB.

Auto Insurance

Do you currently have auto insurance?*

Yes

What is the name of your current auto insurance company?*

If possible, please upload a copy of your current auto insurance policy here:

Max. file size: 100 MB.

Auto Insurance

Liability Coverage

Model*

VIN

Comprehensive

Collision

Roadside Assistance

Rental Reimbursement

Auto Insurance

Please feel free to provide any additional information you think we may need in order to provide the most accurate auto insurance proposal for you.

Homeowners Insurance

When would you like your new homeowner insurance policy to start?*

MM slash DD slash YYYY

Is this for a new home purchase?

Yes

Is there a mortgagee / lienholder?

Yes

Will this policy be paid via mortgage escrow?

Yes

Do you have a trust that needs to be listed on the home policy?

Yes

Please provide details related to the trust:

Is the property address the same as your previously entered home address?*

Yes

Please enter the property address:*

Street Address City State ZIP Code

If you have a current homeowners insurance policy on this house, please upload a copy here.

Max. file size: 100 MB.

Homeowners Insurance

How will this home be used?*

Primary Residence

Secondary Residence

Seasonal Residence

What year was the home built?

Home Square Footage (living space):

When was the roof last updated?

What type of roof is on the house?

Please Specify the Roof Type:

Does the home have solar panels?*

Yes

Are the solar panels owned or leased?*

Owned

Leased

Approximate value of solar panels:*

Homeowners Insurance

Are there any dogs on the premises?*

Yes

Please list all dogs below:

Breed

Any history of biting? (Yes/No)

Is there a swimming pool on the premises?*

Yes

Is the pool fenced with a locking gate?*

Yes

Is there a trampoline on the premises?*

Yes

Homeowners Insurance

Desired amount of dwelling coverage:

You can skip this if you aren't sure.

Desired Policy Deductible:

The deductible is the amount you will pay if you have a claim.

Please specify your desired deductible:

Please select all security devices that are present:

Deadbolt Locks

Fire Extinguisher

Local Smoke/Fire Alarm

Local Burglar Alarm

Monitored Fire Alarm

Monitored Burglar Alarm

Automatic Water Sensors

Please feel free to provide any additional information you think we may need in order to provide the most accurate homeowner insurance proposal for you.

Renters Insurance

When would you like your new renters insurance policy to start?*

MM slash DD slash YYYY

Type of Rental Dwelling:*

Name of the Apartment Complex:*

Is the address the same as your previously entered home address?*

Yes

What is the correct property address?*

Street Address City State ZIP Code

If you have a current renters insurance policy, please upload a copy here.

Max. file size: 100 MB.

Renters Insurance

Desired amount of Personal Property Coverage:*

Please specify your desired amount of Personal Property Coverage:*

This is coverage for all of your personal belongings (clothing, furniture, electronics, dishes, etc.)

Desired amount of Personal Liability Coverage:

Please check with your landlord or property manager. Your rental agreement may include a required minimum amount of personal liability coverage.

Please feel free to provide any additional information you think we may need in order to provide the most accurate renters insurance proposal for you.

Landlord Dwelling

When would you like your new Landlord Dwelling insurance policy to start?*

MM slash DD slash YYYY

Is there a mortgagee / lienholder?

Yes

Will this policy be paid via mortgage escrow?

Yes

Mortgagee / Lienholder Name:

Please enter the property address:*

Street Address City State ZIP Code

If you have a current landlord dwelling insurance policy on this house, please upload a copy here.

Max. file size: 100 MB.

Landlord Dwelling

Term of Rental:*

Up to 7 days

Monthly

Annual

What year was the home built?

Home Square Footage (living space):

When was the roof last updated?

What type of roof is on the house?

Please Specify the Roof Type:

Landlord Dwelling

Is there a swimming pool on the premises?*

Yes

Is the pool fenced with a locking gate?*

Yes

Is there a trampoline on the premises?*

Yes

Landlord Dwelling

Desired amount of dwelling coverage:

You can skip this if you aren't sure.

Desired Policy Deductible:

The deductible is the amount you will pay if you have a claim.

Please specify your desired deductible:

Please select all security devices that are present:

Deadbolt Locks

Fire Extinguisher

Local Smoke/Fire Alarm

Local Burglar Alarm

Monitored Fire Alarm

Monitored Burglar Alarm

Automatic Water Sensors

Please feel free to provide any additional information you think we may need in order to provide the most accurate homeowner insurance proposal for you.

Mobile / Manufactured Home

When would you like this new policy to start?*

MM slash DD slash YYYY

Is this for a new home purchase?

Yes

Is there a mortgagee / lienholder?

Yes

Will this policy be paid via mortgage escrow?

Yes

Mortgagee / Lienholder Name:

Is the property address the same as your previously entered home address?*

Yes

Please enter the property address:*

Street Address City State ZIP Code

If you have a current insurance policy on this home, please upload a copy here.

Max. file size: 100 MB.

Mobile / Manufactured Home

How will this home be used?*

Primary Residence

Secondary Residence

Seasonal Residence

Is it located in an approved park?*

Yes

What is the name of the park?*

Mobile / Manufactured Home

Make (if known)

Model Year*

Width (ft.)

Length (ft.)

Is the home tied down?*

Yes

Is there skirting around the foundation?

Yes

Main Exterior Wall Material:

Please Specify Exterior Wall Material:

When was the roof last updated?

What type of roof is on the house?

Please Specify the Roof Type:

Mobile / Manufactured Home

Is there a swimming pool on the premises?*

Yes

Is the pool fenced with a locking gate?*

Yes

Is there a trampoline on the premises?*

Yes

Mobile / Manufactured Home

Desired amount of dwelling coverage:

You can skip this if you aren't sure.

Desired Policy Deductible:

The deductible is the amount you will pay if you have a claim.

Please specify your desired deductible:

Please select all security devices that are present:

Deadbolt Locks

Fire Extinguisher

Local Smoke/Fire Alarm

Local Burglar Alarm

Monitored Fire Alarm

Monitored Burglar Alarm

Automatic Water Sensors

Please feel free to provide any additional information you think we may need in order to provide the most accurate homeowner insurance proposal for you.

Do you have any additional properties you want us to quote?*

Property Type*

Address of Additional Property to Quote*

Street Address Address Line 2 City State ZIP Code

Please feel free to provide any additional information you think we may need in order to provide the most accurate homeowner insurance proposal for you.

Motorcycle / ATV

When would you like this new insurance policy to start?*

MM slash DD slash YYYY

How many years of experience do you have operating motorcycles or ATV's?*

If you have a current motorcycle or ATV policy, please upload a copy here.

Max. file size: 100 MB.

Motorcycle / ATV

Your Driver's License Number:*

Your Driver's License State:*

Spouse's Driver's License Number:*

Spouse's Driver's License State:*

Domestic Partner's Driver's License Number:*

Domestic Partner's Driver's License State:*

Are there additional drivers in your household?*

Yes

Additional Household Drivers:*

Driver Name

Relationship (Child, Parent, etc.)

Date of Birth

Driver's License Number

Driver's License State

Motorcycle / ATV

List all Motorcycles/ATV's below:*

Year

Make

Model

VIN (if available)

Collision Deductible

Comprehensive Deductible

Please feel free to provide any additional information you think we may need in order to provide the most accurate auto insurance proposal for you.

Motorhome / Camper

When would you like this new insurance policy to start?*

MM slash DD slash YYYY

Your Driver's License Number:*

Your Driver's License State:*

Spouse's Driver's License Number:*

Spouse's Driver's License State:*

Domestic Partner's Driver's License Number:*

Domestic Partner's Driver's License State:*

Are there additional drivers in your household?*

Yes

Additional Household Drivers:*

Driver Name

Relationship (Child, Parent, etc.)

Date of Birth

Driver's License Number

Driver's License State

Motorhome / Camper

List all Motorhomes/Campers below:*

Year

Make

Model

VIN (if available)

Collision Deductible

Comprehensive Deductible

Storage location when not in use:*

Please feel free to provide any additional information you think we may need in order to provide the most accurate Motorhome/Camper insurance proposal for you.

Boat / Watercraft

When would you like this new insurance policy to start?*

MM slash DD slash YYYY

How many years of experience do you have operating watercraft?*

If you have a current Boat/Watercraft policy, please upload a copy here.

Max. file size: 100 MB.

Boat / Watercraft

Your Driver's License Number:*

Your Driver's License State:*

Spouse's Driver's License Number:*

Spouse's Driver's License State:*

Domestic Partner's Driver's License Number:*

Domestic Partner's Driver's License State:*

Are there additional operators in your household?*

Yes

Additional Household Operators:*

Driver Name

Relationship (Child, Parent, etc.)

Date of Birth

Driver's License Number

Driver's License State

Boat / Watercraft

List all Boats/Watercrafts below:*

Year

Make

Model

VIN (if available)

Collision Deductible

Comprehensive Deductible

Please feel free to provide any additional information you think we may need in order to provide the most accurate Boat/Watercraft insurance proposal for you.

Personal Liability Umbrella

When would you like this new policy to start?*

MM slash DD slash YYYY

Desired amount of liability coverage*

If you have a current Personal Liability Umbrella policy, please upload a copy here.

Max. file size: 100 MB.

Personal Liability Umbrella

Number of Household Vehicles*

Number of Owner-Occupied Homes*

Number of Rental Units Owned*

Number of Boats/Watercrafts*

Number of Household Members Under the age of 25*

Number of Household Off-Road Vehicles*

Number of Household Motorcycles

Personal Liability Umbrella

Is there a business operated on the residence premises?*

Yes

Description of Business*

Is any farming conducted on the residence premises?*

Yes

Description of farming operations on residence premises*

Does any member of the household hold an elected office or a high-profile position?*

Yes

Please describe the elected office or high-profile position*

Please feel free to provide any additional information you think we may need in order to provide the most accurate Personal Liability Umbrella proposal for you.

Life Insurance

How much life insurance coverage do you need?*

What type of life insurance do you want?

Term Life

Whole Life

Universal Life

Burial Policy

Do you take any prescription medications?*

Yes

Please list all prescription medications you are currently taking*

Medication

Dosage

Frequency

Condition Treated

Are both of your biological parents still living?*

Yes

Did either of them die prior to age 60 due to a heart-related condition?*

Yes

Please provide any additional information you think we may need in order to provide the most accurate Life Insurance proposal for you.

Tell us what you're looking for...

Please provide some details below and we'll see what we can find for you!*

One last question...

How would like to receive your proposal?*

Phone Call

Text Message

Postal Mail

Please verify your mailing address:*

Street Address City State ZIP Code

All done!

Once you're finished, go ahead and click "Submit" and we'll get to work for you as quickly as possible.

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If you have any questions call or email for help.

Call 863-662-3134 Send A Message

If you have any questions call or email for help.

Call 863-662-3134 Send A Message