Request a Quote – Regency Insurance & Financial Group

Quote Type Requesting *

Name *

First

Last

Business / Organization *

Federal Tax ID

Email *

Phone *

Date of Birth *

Employer *

Occupation *

Est. miles to employment *

Licensed at age? *

Drivers License *

DL State *

State Abbrev.

Vehicle #1 Year *

Vehicle #1 Make *

Vehicle #1 Model *

Vehicle #1 Vin Number

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Will the vehicle/s be used for any ride sharing service? ex. Uber, Lift *

Yes
No

Is your vehicle stored at a different address than your home? *

Yes
No

Garaging Address #1 *

Address Line 1

Address Line 2

City

State

Zip Code

Additional drivers? *

Yes
No

How many additional drivers *

Additional driver's name (Driver #2 ) *

First

Last

Date of Birth (Driver #2 ) *

Which vehicle will they drive? *

Employer (Driver #2 ) *

Occupation (Driver #2 ) *

Est. miles to emp. (Driver#2 ) *

Licensed at age? (Driver #2 ) *

Drivers License (Driver #2 ) *

DL State (Driver #2 ) *

State Abbrev.

Live's at same address as proposed insured? (Driver #2 ) *

Yes
No

Address of additional driver #2 *

Address Line 1

Address Line 2

City

State

Zip Code

Additional driver's name (Driver #3 ) *

First

Last

Date of Birth (Driver #3 ) *

Which vehicle will they drive? *

Employer (Driver #3 ) *

Occupation (Driver #3 ) *

Est. miles to emp. (Driver#3 ) *

Licensed at age? (Driver #3 ) *

Drivers License (Driver #3 ) *

DL State (Driver #3 ) *

State Abbrev.

Live's at same address as proposed insured? (Driver #3 ) *

Yes
No

Address of additional driver #3 *

Address Line 1

Address Line 2

City

State

Zip Code

Additional driver's name (Driver #4 ) *

First

Last

Date of Birth (Driver #4 ) *

Which vehicle will they drive? *

Employer (Driver #4 ) *

Occupation (Driver #4 ) *

Est. miles to emp. (Driver#4 ) *

Licensed at age? (Driver #4 ) *

Drivers License (Driver #4 ) *

DL State (Driver #4 ) *

State Abbrev.

Live's at same address as proposed insured? (Driver #4 ) *

Yes
No

Address of additional driver #4 *

Address Line 1

Address Line 2

City

State

Zip Code

Additional driver's name (Driver #5 ) *

First

Last

Date of Birth (Driver #5 ) *

Which vehicle will they drive? *

Employer (Driver #5 ) *

Occupation (Driver #5 ) *

Est. miles to emp. (Driver#5 ) *

Licensed at age? (Driver #5 ) *

Drivers License (Driver #5 ) *

DL State (Driver #5 ) *

State Abbrev.

Live's at same address as proposed insured? (Driver #5 ) *

Yes
No

Address of additional driver #5 *

Address Line 1

Address Line 2

City

State

Zip Code

Additional Vehicles? *

Yes
No

How many additional vehicles? *

Vehicle #2 Year *

Vehicle #2 Make *

Vehicle #2 Model *

Vehicle #2 Vin Number

Additional vehicle #2 stored at same address? *

Yes
No

Garaging Address #2 *

Address Line 1

Address Line 2

City

State

Zip Code

Vehicle #3 Year *

Vehicle #3 Make *

Vehicle #3 Model *

Vehicle #3 Vin Number

Additional vehicle #3 stored at same address? *

Yes
No

Garaging Address #3 *

Address Line 1

Address Line 2

City

State

Zip Code

Vehicle #4 Year *

Vehicle #4 Make *

Vehicle #4 Model *

Vehicle #4 Vin Number

Additional vehicle #4 stored at same address? *

Yes
No

Garaging Address #4 *

Address Line 1

Address Line 2

City

State

Zip Code

Vehicle #5 Year *

Vehicle #5 Model *

Vehicle #5 Make *

Vehicle #5 Vin Number

Additional vehicle #5 stored at same address? *

Yes
No

Garaging Address #5 *

Address Line 1

Address Line 2

City

State

Zip Code

Address of Property *

Address Line 1

Address Line 2

City

State

Zip Code

Purchase Date *

Purchase Price *

Year Built *

SqFt *

The property 20 years or older? *

Yes
No

Do you currently live at the above address? *

Yes
No

Who is the property intended to be occupied by? *

Tenant
Owner

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Previous Carrier *

Policy # *

Expiration Date *

Premium *

Do you have a dog? *

Yes
No

Number of dogs? *

Breed *

Bite history *

Roof type *

Replaced / Repaired? *

Replaced
Repaired
n/a

Date Completed *

Year roof last completely replaced? *

Garage type *

How many cars? *

Number of Bedrooms *

Number of Baths *

Fireplace? *

Fire Extinguisher *

Yes
No

Smoke Detector *

Yes
No

Dead Bolt/s *

Yes
No

Type of Heating System *

Year heating system updated? *

Supplemental heating source? *

Yes
No

Year water heater replaced? *

Active Alarm System *

Yes
No

Alarm Company *

Proof Available *

Yes
No

Plumping *

Replaced / Repaired? *

Replaced
Repaired
n/a

Date Completed *

Year plumping system updated *

Partial or Complete? *

Electrical *

Rewired *

Yes
No

Date Completed *

Year electrical system updated *

Partial or Complete? *

Is all the wiring connected to circuit breakers? *

Yes
No

Is there any aluminum wiring? *

Yes
No

Gated Community *

Yes
No

Guarded *

Yes
No

Releasable Security Bars *

Yes
No

Solar Panels *

Yes
No

Total # of Panels *

Leased or Owned *

Leased
Owned

Types of Life Protection *

Index Universal Life
Term Life
Variable Universal Life
Whole Life

Please select a type of protection your interested in receiving a quote. You may select more than one.

Types of Retirement Plans *

Please select a type of retirement plan your interested in receiving a quote. You may select more than one.

Types of Annuities *

Additional Comments

Please use the given area to provide any additional details deemed necessary.

Request a quote by filling out the information below or get it faster by calling! 760-837-3761