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(954) 541-9232

Auto

Motorcycle

Boat

Homeowners

General Liability

Commercial Property

Cyber Liability

Health

Auto Insurance Questionnaire

General Informatiion:

Insured Full Name

Phone Number

Garaging address

# of drivers/household members

Homeowners or Rent

Currently insured?

Drivers:

Name

Date of Birth

Sex

Marital Status

Occupation

Driver’s License #

Years w/License

State or Country Issued

Name

Date of Birth

Sex

Marital Status

Occupation

Driver’s License #

Years w/License

State or Country Issued

Name

Date of Birth

Sex

Marital Status

Occupation

Driver’s License #

Years w/License

State or Country Issued

Name

Date of Birth

Sex

Marital Status

Occupation

Driver’s License #

Years w/License

State or Country Issued

Vehicle(s) Information:

Year

Make

Model

Vin Number

Lease or Purchase

Desired coverage

Desired deductibles

Year

Make

Model

Vin Number

Lease or Purchase

Desired coverage

Desired deductibles

Year

Make

Model

Vin Number

Lease or Purchase

Desired coverage

Desired deductibles

Prior Coverage:

Prior Company

Length of Coverage

Total Premium

Premium

Accidents in the last 3 years

Additional Information for us to know:

Boat Insurance Questionnaire

Name of Owner(s)

Telephone Number

Garaging Address

Mailing Address (If Different)

Marital Status

Driver’s License

Date of Birth

Additional information

Current /Prior Insurance

How long with Current Insurance

Coverages

Expiration Date

Any claims in the past 5 years?

Homeowner?

Boat make

Boat Model

Year

Vessel #/ VIN number

How many feet

Inboard/outboard

Note: Please upload all corresponding documents: Boat Registration, Drivers license, Boaters Course completion, Boaters License, etc.

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Homeowners Insurance Questionnaire

Name

Phone number

Property Address

Mailing address (if different than property address

Rental property or Owneroccupied

New purchase/currently insured/uninsured

Shutters/no shutters

Roof type—Tile/shingle/cement/metal/other

Original year of Roof? Year repaired/replaced? Updates?

AC, Plumbing, and electrical updates? If so, what years?

Flood policy required? If so, is there an active policy?

Claims in last 5 years? If so, explain. (open or closed) Type of claim.

Valid wind mitigation or 4-point inspection available?

Note: Please attach all corresponding documents: Wind mitigation inspection /4 point inspection/elevation certificate/ Drivers licenses/ Current insurance declarations page/ lender requirement for closing

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General Liability Questionnaire

General Information:

Applicant name

Telephone number

Company Information:

Legal Business name

FEIN:

Partnership/Corp/LLC

Business address

Website

Phone number

Years in Business

Detailed description of business:

Prior Coverage (if applicable):

Prior Company

Length of Coverage

Total Premium

Renewal date

Any claims in the past?

Additional Information: Please explain your desired coverages.

Health Insurance Questionnaire

Named Insured:

Address:

Household annual income:

Do you have current insurance?

How many Dependents?

Household members:

Name

Date of Birth

Smoker?

Desired Coverage/ Comment :

*If more than provided please attach.

Note: Please upload any other documents to our website via chat bot or email to info@madinsurance.com

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Signature

Get in Touch

9050 Pines Blvd, Suite 415-418
Pembroke Pines FL 33024

Phone: 954.541.9232 / 305. 594.8696

Email: info@mad-insurance.com

Hours of Operation

MONDAY - FRIDAY

9:30AM - 6PM

SATURDAY & SUNDAY

By appointment only

We are available 24/7 via text

(954) 541-9232

Get A Quote

Contact Us

Drop us a line and one of our representatives will get back to you.

Request a quote

Email us

Call us now

(954) 541-9232

Auto Insurance Questionnaire

General Informatiion:

Drivers:

Vehicle(s) Information:

Prior Coverage:

MOTORCYCLE QUESTIONNAIRE

Rider Information:

Vehicle Information:

Policy Information:

Coverage Requested:

Boat Insurance Questionnaire

Homeowners Insurance Questionnaire

General Liability Questionnaire

General Information:

Company Information:

Prior Coverage (if applicable):

Commercial Property Questionnaire

CONTACT INFORMATION

TELL US ABOUT YOUR OPERATIONS

TELL US ABOUT YOUR BUILDING

Year Updated

Security: check all that apply

LOSS HISTORY

COVERAGE OPTION

CYBER LIABILITY QUESTIONNAIRE

A. General

B. Financial Information

Revenue ($CDN:

C. Employees

D. Data Management

E. Internal Controls/Processes

1. Does the company have the following in place:

F. Third Parties

Please note that the content of this questionnaire is for indication purposes only and further details may be required in order to bind coverage.

Health Insurance Questionnaire

Household members:

*If more than provided please attach.

Note: Please upload any other documents to our website via chat bot or email to info@madinsurance.com

Get in Touch

Hours of Operation