[Dennis Bruce Quote Form] – Breathe Insurance

Dennis Bruce Personal Quote Form

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EZLynx App ID*
Email*
Select Policy or Polcies to Quote

Select Quote Request Type
Critical Same Day Quote Request Cut Off Times:
• Remarket Monoline Policies – 4 p.m.
• Remarket Package Policies – 3 p.m.
• New Business Monoline Policies – 3 p.m.
• New Business Package Policies – 24 HR Completion Time
Enter Date of Quote Request*
MM slash DD slash YYYY
Current Expiration Date:
MM slash DD slash YYYY

If Remarketing
Critical Due Date
MM slash DD slash YYYY
Send Quote Form to*

PH Team

Me
How did they hear about you?
If New Client
Who referred them?
Which Insurance Company Website?
Marketing Preference*
If this is a New Business Quote, please provide:
• Deducticble
• Limit of Liability
• Perferred Dollar Per Sq. Ft.
• And so on…
Notes To Quoting
Select a Single Policy or Multiple Policies*
Home Quote Form

Property Type*
Home
Condo
Secondary
Property Address
Street Address City State ZIP Code
Year Purchased
Month
Day
Year
Year Built
Month
Day
Year
Square Feet of Your Home?
Has your Roof Been Updated?
Yes
No
If so, when?
Month
Day
Year
Is Your Home Vacant of for Sale?
Vacant
For Sale
Neither
Is There Existing Damage to Your Home?
Yes
No
Custom or Designer Materials In:
Kitchen
Bathrooms
Previous Address
If you have owned this property less than 5 years, what is your prior address?

Street Address City State ZIP Code
Do you have an HOA?
Yes
No
Relationship Status
Married
Domestic Partner
Single
Divorced
Widowed
Widower
Date of Birth
Month
Day
Year
Occupation
If applicable, Spouse/Partner DOB
Month
Day
Year
Spouse/Partner Occupation
Any claims filed in the last 5 years?
Yes
No
Describe nature and date of claim
Any special High Value items you're concerned about?
Yes
No
What Kind of High Value Items and What is the Value?
Sprinkler system inside the home?
Yes
No
If so, is the system:
Full
Partial
Is the property in a gated community?
Yes
No
If gated, is it guard gated?
Yes
No
Burglar and Fire System Connection
Are they connected to a monitoring company?
Yes
No
If yes, who is the monitoring vendor?
Do you have any of the following?
Pool
Jacuzzi
Water Slide
Diving Board
None
Does the Property have Solar Panels?*
Are Solar Panels owned or leased?
How many Solar Panels does the Property have?
Do you have any of the following?
Live-In Nanny
Regular Service People
Tree House
Skate Board Ramps
Homes Based Business
Wood or Pellet Stove
Farming Operations
None
Do you have a trampoline?
Yes
No
If so, does it have a safety net?
Yes
No
Do you have dogs?
Yes
No
If so, what breeds?
Do you have any of the following polices?
Earthquake
Flood
Umbrella
None
Term Life Insurance
Do you have term life insurance outside your employer that is at least ten times your annual income?
Yes
No
If so, how long have you had the policy?
Auto Quote Form

Driver Count*
How many drivers are insured on your policy?
Home Address
Street Address City State ZIP Code
Driver #1

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Age First Licensed*
Any driving violations or accidents? Explain*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Occupation*
Work/School Address*
Name of Business/School Street Address City State ZIP Code
Driver #2

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Age First Licensed*
Any driving violations or accidents? Explain*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Occupation*
Work/School Address*
Name of Business/School Street Address City State ZIP Code
Driver #3

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Age First Licensed*
Any driving violations or accidents? Explain*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Occupation*
Work/School Address*
Name of Business/School Street Address City State ZIP Code
Driver #4

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Age First Licensed*
Any driving violations or accidents? Explain*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Occupation*
Work/School Address*
Name of Business/School Street Address City State ZIP Code
Driver #5

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Age First Licensed*
Any driving violations or accidents? Explain*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Occupation*
Work/School Address*
Name of Business/School Street Address City State ZIP Code
Driver #6

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Age First Licensed*
Any driving violations or accidents? Explain*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Occupation*
Work/School Address*
Name of Business/School Street Address City State ZIP Code
Auto Identification

Insured Vehicles*
How many insured vehicles to you have on your auto insurance policy?
Vehicle #1

Year*
Make*
Model*
VIN #*
Current Odometer Reading*
Use*
Commute
Pleasure
Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Vehicle #2

Year*
Make*
Model*
VIN #*
Current Odometer Reading*
Use*
Commute
Pleasure
Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Vehicle #3

Year*
Make*
Model*
VIN #*
Current Odometer Reading*
Approximate Purchase Date*
Month
Day
Year
Use*
Commute
Pleasure
Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Vehicle #4

Year*
Make*
Model*
VIN #*
Current Odometer Reading*
Approximate Purchase Date*
Month
Day
Year
Use*
Commute
Pleasure
Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Vehicle #5

Year*
Make*
Model*
VIN #*
Current Odometer Reading*
Approximate Purchase Date*
Month
Day
Year
Use*
Commute
Pleasure
Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Vehicle #6

Year*
Make*
Model*
VIN #*
Current Odometer Reading*
Approximate Purchase Date*
Month
Day
Year
Use*
Commute
Pleasure
Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
General Vehicle Questions

Aftermarket Options*
Do you have additional aftermarket equipment?
Yes
No
If so, which auto, type of equipment, and value?*
Years With Provider*
How many years have you been with your current auto insurance company?
Do you have an umbrella insurance policy?*
Yes
No
Do you have an auto provided by your employer?*
Yes
No
Do you have a AAA membership?*
Yes
No
Term Life Policy*
Do you have term life insurance outside of your employer that is at least ten times your annual income?
Yes
No
If so, how long have you had the term life?*
Discount Questions

Student Drivers*
Do any drivers on your policy under the age of 25 attend school full time and carry a 3.0 or above GPA?
Yes
No
Attendance Proof*
If so, can you provide a copy of the report card as proof of this discount?
Yes
No
College Grads*
Do any drivers have a degree from a 4 year accredited college or university located in the U.S.?
Yes
No
Graduation Proof*
Would you be able to provide a copy of the degree for the discount?
Yes
No
If so, list who, school name, and degree type:*
Rental Property Form

Property Address*
Street Address City State ZIP Code
Is the mailing address the same as the property address?*
Yes
No
Mailing Address*
Street Address City State ZIP Code
Year Purchased*
Owned Less Than 5 Years
If you have owned less than 5, what is your prior address?

Street Address City State ZIP Code
Do you have an HOA?*
Yes
No
Relationship Status*
Your Date of Birth*
Month
Day
Year
Your Occupation*
Your spouse/partner Date of Birth*
Month
Day
Year
Their Occupation*
Is there a tenant?*
Yes
No
If yes, are they full time or part time?*
Property Use*
Yes
No
Is the property used as a seasonal rental, such as AirBNB, Home Away?
Do you have a property management company?*
Yes
No
Is the property in a Trust, LLC, Corp or Partnership?*
Yes
No
Any Claims filed in last 5 years?*
Yes
No
If yes, describe and list approximate date:*
Do you have a Sprinkler System inside you home?*
Yes
No
If so, is the system:*
Full
Partial
Is the property located in a Gated Community?*
Yes
No
If gated, is it guard gated?*
Yes
No
Do you have any of the following?*
Pool
Jacuzzi
Both
Do you have Earth Quake insurance?*
Yes
No
Do you have Flood insurance?*
Yes
No
Renter's Quote Form

Property Address*
Street Address City State ZIP Code
Your Date of Birth*
Month
Day
Year
Select your personal property amount of coverage:*
Do you have any Jewelry that should be insured?*
Yes
No
If yes, describe and list its value:*
Do you have dogs?*
Yes
No
If so, what breeds?*
Any High Value items you’re concerned about?*
Yes
No
What Kind of High Value Items and What is the Value?*
Are there any special items that you're concerned about?*
Yes
No
Are you required to provide proof of insurance to your property manager?*
Yes
No
Motorcycle/ATV Form

How many Driver's operate your Motorcycle/ATV?*
Home Address*
Street Address City State ZIP Code
Driver #1

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Age First Licensed*
Any driving violations or accidents?*
Yes
No
Driver #2

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Age First Licensed*
Any driving violations or accidents?*
Yes
No
Driver #3

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Age First Licensed*
Any driving violations or accidents?*
Yes
No
Driver #4

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Age First Licensed*
Any driving violations or accidents?*
Yes
No
Driver #5

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Age First Licensed*
Any driving violations or accidents?*
Yes
No
Driver #6

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Age First Licensed*
Any driving violations or accidents?*
Yes
No
Motorcycle/ATV Identification

How many Motorcycle/ATV's need insured?*
Motorcycle/ATV #1

Year*
Make*
Model*
VIN #*
Miles Driven Per Year*
Primary Driver*
First Last
Motorcycle/ATV #2

Year*
Make*
Model*
VIN #*
Miles Driven Per Year*
Primary Driver*
First Last
Motorcycle/ATV #3

Year*
Make*
Model*
VIN #*
Miles Driven Per Year*
Primary Driver*
First Last
Motorcycle/ATV #4

Year*
Make*
Model*
VIN #*
Miles Driven Per Year*
Primary Driver*
First Last
Motorcycle/ATV #5

Year*
Make*
Model*
VIN #*
Miles Driven Per Year*
Primary Driver*
First Last
Motorcycle/ATV #6

Year*
Make*
Model*
VIN #*
Miles Driven Per Year*
Primary Driver*
First Last
Motorcycle/ATV General Questions

Do you have additional aftermarket equipment?*
Yes
No
If so, how much aftermarket equipment?*
Do you have an Umbrella insurance policy?*
Yes
No
Boat Form

Home Address*
Street Address City State ZIP Code
Year*
Make*
Model*
Hull #*
Length*
Motor Style
Inboard
Outboard
Horse Power*
Cost New*
Current Value*
Do you have separate towing coverage?*
Yes
No
Do you have scheduled equipment?*
Yes
No
Years of Operating Experience:*
Do you have any marine certifications?*
Yes
No
Where is it stored?*
Street Address City State ZIP Code
Is it stored in a secured or fenced in area?*
Yes
No
Motor Home/Travel Trailer Form

How many Driver's operate your Motor Home?*
Home Address*
Street Address City State ZIP Code
Driver #1

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Age First Licensed*
Any Driving violations or accidents?*
Yes
No
Driver #2

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Age First Licensed*
Any Driving violations or accidents?*
Yes
No
Driver #3

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Age First Licensed*
Any Driving violations or accidents?*
Yes
No
Driver #4

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Age First Licensed*
Any Driving violations or accidents?*
Yes
No
Driver #5

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Age First Licensed*
Any Driving violations or accidents?*
Yes
No
Driver #6

Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
Male
Female
Marital Status*
Married
Unmarried
Widowed
Widower
Age First Licensed*
Any Driving violations or accidents?*
Yes
No
Motor Home/Travel Trailer Identification

Number of Motor Home/Travel Trailer needing insured?*
Motor Home/Travel Trailer #1

Year*
Make*
Model*
VIN #*
Use*
Commute
Pleasure
Business
Miles Driven Per Year*
Primary Driver*
First Last
Motor Home/Travel Trailer #2

Year*
Make*
Model*
VIN #*
Use*
Commute
Pleasure
Business
Miles Driven Per Year*
Primary Driver*
First Last
Motor Home/Travel Trailer #3

Year*
Make*
Model*
VIN #*
Use*
Commute
Pleasure
Business
Miles Driven Per Year*
Primary Driver*
First Last
Motor Home/Travel Trailer #4

Year*
Make*
Model*
VIN #*
Use*
Commute
Pleasure
Business
Miles Driven Per Year*
Primary Driver*
First Last
Motor Home/Travel Trailer #5

Year*
Make*
Model*
VIN #*
Use*
Commute
Pleasure
Business
Miles Driven Per Year*
Primary Driver*
First Last
Motor Home/Travel Trailer #6

Year*
Make*
Model*
VIN #*
Use*
Commute
Pleasure
Business
Miles Driven Per Year*
Primary Driver*
First Last
Motor Home/Travel Trailer General Questions

Do you have additional aftermarket equipment?*
Yes
No
If so, how much what kind of aftermarket equipment?*
Where is this stored?*
Primary Home
Other
Of "Other" list address:*
Street Address City State ZIP Code
Do you have an Umbrella insurance policy?*
Yes
No
Current Odometer*
Upload General Documents

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Dennis Bruce Personal Quote Form

Required Information

Select Policy or Polcies to Quote

Home Quote Form

Auto Quote Form

Driver #1

Driver #2

Driver #3

Driver #4

Driver #5

Driver #6

Auto Identification

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

Vehicle #5

Vehicle #6

General Vehicle Questions

Discount Questions

Rental Property Form

Renter's Quote Form

Motorcycle/ATV Form

Driver #1

Driver #2

Driver #3

Driver #4

Driver #5

Driver #6

Motorcycle/ATV Identification

Motorcycle/ATV #1

Motorcycle/ATV #2

Motorcycle/ATV #3

Motorcycle/ATV #4

Motorcycle/ATV #5

Motorcycle/ATV #6

Motorcycle/ATV General Questions

Boat Form

Motor Home/Travel Trailer Form

Driver #1

Driver #2

Driver #3

Driver #4

Driver #5

Driver #6

Motor Home/Travel Trailer Identification

Motor Home/Travel Trailer #1

Motor Home/Travel Trailer #2

Motor Home/Travel Trailer #3

Motor Home/Travel Trailer #4

Motor Home/Travel Trailer #5

Motor Home/Travel Trailer #6

Motor Home/Travel Trailer General Questions

Upload General Documents