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Name*

Email*

Phone*

Type of Insurance*

Personal Insurance Survey

Are you interested in Flood Insurance?

Yes

Are you interested in Earthquake Insurance?

Yes

Are you interested in Water Sewage Backup?

Yes

Do you have any Jewelry, Furs, Art, Guns, Collectables, or Bicycles you are interested in insuring?

Yes

Do you have any Businesses in the Home?

Yes

Do you have extra Outbuildings / Other Structures?

Yes

Do you do any Farming at / away from residence or lease the property to farmers?

Yes

Has the Deed been changed on your Property, ex) LLC or Trust?

Yes

Are you interested in Pet Insurance?

Yes

Do you have a Company Car?

Yes

Do you have any collector/antique autos?

Yes

Are all vehicles on your policy titled to you?

Yes

Are all licensed drivers that reside in your household listed on your policy?

Yes

Do you drive for Lyft, Uber or any other ridesharing service?

Yes

Do you deliver pizza or other goods in your car?

Yes

Do you drive your vehicle for business?

Yes

Are you comfortable with your current liability limits?

Yes

Do you have any motorcycles/ATV/golf carts?

Yes

Do you have any boats or personal watercrafts?

Yes

Do you have any RV/travel trailer/camper?

Yes

Do you own any other property besides your main home: (rental, secondary homes, vacant land)?

Yes

Are you interested in a personal umbrella that gives additional liability over your home and auto policies?

Yes

Are you interested in Life insurance?

Yes

Are you interested in Disability Insurance?

Yes

Are you interested in Long-Term Care?

Yes

Are you interested in an Annuity?

Yes

Are you interested in Financial Planning / Investment Services?

Yes

Do you have health/dental/vision insurance?

Yes

Are you interested in Medicare supplement insurance?

Yes

Are you interested in insurance for your next vacation?

Yes

Are you interested in insurance for your next vacation?

Yes

Do you own a business?

Yes

If yes, do you carry business insurance?

Yes

Commercial Insurance Survey

Business Name*

Have you had a change in your business' entity? (such as a change to an Inc. or LLC)

Yes

What are your annual Gross Receipts?

Annual Payroll?

Have you added or lost any employees?

Yes

What is the number of FT Employees?

What is the number of PT Employees?

What is the number of Officers?

Worker’s compensation laws are being enforced. At the minimum you can be fined by the state if you fail to carry coverage. Do you need to discuss this with us?

Yes

Have you had any changes in the type of work you are doing?

Yes

Have you purchased or sold any property, vehicles or equipment?

Yes

Do you need to remove or add any vehicles or leinholders on your auto policy?

Yes

Do you need to remove or add any drivers?

Yes

Have you made any building updates- roof/ heat & air /plumbing and/or electrical?

Yes

Would you like a quote or more information on Employment Practices Liability?

Yes

Would you like a quote or more information on Utility Services Coverage?

Yes

Do you conduct business over the internet? (such as orders, pmts, etc)

Yes

Would you like a quote or more information on Data Breach Coverage or Cyber Liability?

Yes

Would you like an Umbrella quote? We recommend all business have this!

Yes

Have there been any changes to your local building ordinances that require additional coverage?

Do you use drones in your business?

Yes

Erie Rate

Policy Number*

Location Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Year When Last FULLY REPLACED*

What Is The Roof Type?*

If You Selected Other, Please Specify:

Do You Have A Swimming Pool On The Premises?*

Yes

If You Selected Yes, Where Is It Located?

Feet To Fire Hydrant*

Miles To Fire Department*

This field is for validation purposes and should be left unchanged.

Customer Reviews

Breeden Insurance has been highly responsive to quote requests. The agents have...

Evan M

I have been with Breeden Insurance for 10 years. They have always provided me...

Jacob W

Very professional group. Highly recommended. 10 out of 10. Thanks for...

Ryan L

Very happy with the easily affordable costs that Breeden Insurance offers when...

Kingsley S

The always helpful staff is friendly without the aggressive tendencies...

Gregg C

...Their customer service is the best!

Tonia S Pennington

A great business that cares for their customers

Tiffany M Young

...Helped us in finding the best possible premium to meet our property insurance needs

Bruce W

I would recommend them if you want to change!

Kathy S

Melissa E. handles our business needs and does an outstanding job!

Vivian M Newsome

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Personal Insurance Survey

Commercial Insurance Survey

Erie Rate

Customer Reviews

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