[Breathe Insurance Application]

Breathe Insurance Application

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Your Information

Name*
First Last
Email*
Phone*
How did you hear about us?*
Who referred you?*
Which Insurance Company Website?*
Select a Single Policy or Multiple Policies*
Home Quote Form

Current Insurance Company
Property Type*
- Home
- Condo
- Secondary
Deductible
Liability Limits
Property Address*
Street Address City State ZIP Code
Year Purchased
Month
Day
Year
Year Built*
Month
Day
Year
Square Feet of Home?*
Is Home Vacant of for Sale?*
- Vacant
- For Sale
- Neither
Is there Existing Damage to Home?*
- Yes
- No
Have you lived in the home for more than 5 years?
Previous Address
If you have owned this property less than 5 years, what is your prior address?

Street Address City State ZIP Code
Has Roof Been Updated?*
- Yes
- No
If so, when?*
Month
Day
Year
Custom or Designer Materials In:
- Kitchen
- Bathrooms
Do you have an HOA?*
- Yes
- No
Relationship Status*
- Married
- Domestic Partner
- Single
- Divorced
- Widowed
- Widower
Date of Birth*
Month
Day
Year
Occupation*
Spouse/Partner Name
First Last
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 they'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
- Solar Panels
- None
How Many Solar Panels?*
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 they have a trampoline?*
- Yes
- No
If so, does it have a safety net?*
- Yes
- No
Do they have dogs?*
- Yes
- No
If so, what breeds?*
Do they 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

Current Insurance Company
Driver Count*
How many drivers are insured on your policy?
Home Address*
Street Address City State ZIP Code
BI Limits
UMBI Limits
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*
Comprehensive Deductible
Collison Deductible
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*
Comprehensive Deductible
Collison Deductible
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Vehicle #3

Year*
Make*
Model*
VIN #
Comprehensive Deductible
Collison Deductible
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 #
Comprehensive Deductible
Collison Deductible
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 #
Comprehensive Deductible
Collison Deductible
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 #
Comprehensive Deductible
Collison Deductible
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*
Can they provide a copy of the degree for the discount?
- Yes
- No
If so, list who, school name, and degree type:*
Rental Property Form

Current Insurance Company
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*
Primary Insured Date of Birth
Month
Day
Year
Primary Insured Occupation
Your spouse/partner Date of Birth
Month
Day
Year
Secondary Insured 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 they you 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 they youEarth Quake insurance?*
- Yes
- No
Do you have Flood insurance?*
- Yes
- No
Renter's Form

Current Insurance Company
Property Address*
Street Address City State ZIP Code
Primary Insured Date of Birth
Month
Day
Year
Select 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

Current Insurance Company
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

Current Insurance Company
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 they have additional aftermarket equipment?*
- Yes
- No
If so, how much aftermarket equipment?*
Do they have an Umbrella insurance policy?*
- Yes
- No
Boat Form

Current Insurance Company
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

Current Insurance Company
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
Additional information that you would like me to know

Additional Notes
Upload General Documents

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Breathe Insurance Application

Your Information

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 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

Additional information that you would like me to know

Upload General Documents