Canopy Charlottesville Insurance . Insurance Quote

Auto
How many drivers are you looking to insure? (you will be able to assign these drivers to any of your vehicles)
How many vehicles are you looking to insure?

Driver 1 Information
Driver 1 - Name
Driver 1 - Date of Birth
Driver 1 - Occupation: (We will advise if a discount is available for your profession. If so, additional documentation will be required for Underwriting purposes.) Our fax number is 434 220 3432
Driver 1 - Company Name (if applicable)
Driver 1 - Are you a student with a 'B' Average or better?		yesno
Driver 1 - Rated Driver?		yesno
If not a rated driver, why? (ex. never licensed, currently suspended, other insurance, medical, learner's permit, temporary license, explain other reasons)
Driver 1 - Marital Status
Driver 1 - Did you have prior insurance with no breaks?
Driver 1 - How long did you have your prior insurance?
Driver 1 - Driver's License Number
Driver 1 - International Driver's License?		yes no
Driver 1 - SR22 Needed?		yes no
Driver 1 - CDL License?		yes no
Driver 1 - Motorcycle License?		yes no
Driver 1 - Have you had any citations, accidents or have claims been paid out in the past five years?		yes no
If yes, please answer the next 5 questions
What was the make and model of the car you were driving at the time?
Date
Describe the circumstances
Total payout (if applicable)
Who was at fault?

Driver 2 Information
Driver 2 - Name
Driver 2 - Date of Birth
Driver 2 - Occupation: (We will advise if a discount is available for your profession. If so, additional documentation will be required for Underwriting purposes.) Our fax number is 434 220 3432
Driver 2 - Company Name (if applicable)
Driver 2 - Are you a student with a 'B' Average or better?		yesno
Driver 2 - Rated Driver?		yesno
If not a rated driver, why? (ex. never licensed, currently suspended, other insurance, medical, learner's permit, temporary license, explain other reasons)
Driver 2 - Marital Status
Driver 2 - Did you have prior insurance with no breaks?
Driver 2 - How long did you have your prior insurance?
Driver 2 - Driver's License Number
Driver 2 - International Driver's License?		yes no
Driver 2 - SR22 Needed?		yes no
Driver 2 - CDL License?		yes no
Driver 2 - Motorcycle License?		yes no
Driver 2 - Have you had any citations, accidents or have claims been paid out in the past five years?		yes no
If yes, please answer the next 5 questions
What was the make and model of the car you were driving at the time?
Date
Describe the circumstances
Total payout (if applicable)
Who was at fault?

Driver 3 Information
Driver 3 - Name
Driver 3 - Date of Birth
Driver 3 - Occupation: (We will advise if a discount is available for your profession. If so, additional documentation will be required for Underwriting purposes.) Our fax number is 434 220 3432
Driver 3 - Company Name (if applicable)
Driver 3 - Are you a student with a 'B' Average or better?		yesno
Driver 3 - Rated Driver?		yesno
If not a rated driver, why? (ex. never licensed, currently suspended, other insurance, medical, learner's permit, temporary license, explain other reasons)
Driver 3 - Marital Status
Driver 3 - Did you have prior insurance with no breaks?
Driver 3 - How long did you have your prior insurance?
Driver 3 - Driver's License Number
Driver 3 - International Driver's License?		yes no
Driver 3 - SR22 Needed?		yes no
Driver 3 - CDL License?		yes no
Driver 3 - Motorcycle License?		yes no
Driver 3 - Have you had any citations, accidents or have claims been paid out in the past five years?		yes no
If yes, please answer the next 5 questions
What was the make and model of the car you were driving at the time?
Date
Describe the circumstances
Total payout (if applicable)
Who was at fault?

Driver 4 Information
Driver 4 - Name
Driver 4 - Date of Birth
Driver 4 - Occupation: (We will advise if a discount is available for your profession. If so, additional documentation will be required for Underwriting purposes.) Our fax number is 434 220 3432
Driver 4 - Company Name (if applicable)
Driver 4 - Are you a student with a 'B' Average or better?		yesno
Driver 4 - Rated Driver?		yesno
If not a rated driver, why? (ex. never licensed, currently suspended, other insurance, medical, learner's permit, temporary license, explain other reasons)
Driver 4 - Marital Status
Driver 4 - Did you have prior insurance with no breaks?
Driver 4 - How long did you have your prior insurance?
Driver 4 - Driver's License Number
Driver 4 - International Driver's License?		yes no
Driver 4 - SR22 Needed?		yes no
Driver 4 - CDL License?		yes no
Driver 4 - Motorcycle License?		yes no
Driver 4 - Have you had any citations, accidents or have claims been paid out in the past five years?		yes no
If yes, please answer the next 5 questions
What was the make and model of the car you were driving at the time?
Date
Describe the circumstances
Total payout (if applicable)
Who was at fault?
Please list any additional vehicle/driver information in the comment box at the bottom of this form (please specify which of the above vehicles' coverages you would like to match)

Vehicle 1 Information
Vehicle 1 VIN (Vehicle Information Number)
Vehicle 1 Registered Vehicle Owner
Vehicle 1 Usage
Vehicle 1 Annual Mileage
Vehicle 1 Vehicle Type
Vehicle 1 Vehicle Year
Vehicle 1 Vehicle Make
Vehicle 1 Vehicle Model
Vehicle 1 Liability
Vehicle 1 Uninsured/Underinsured Motorist Coverage (UM/UIM)
Vehicle 1 Medical Coverage
Vehicle 1 Comprehensive Coverage
Vehicle 1 Collision Coverage
Vehicle 1 - Do you want towing services?
Vehicle 1 - Do you want car rental services?
Vehicle 1 - Do you want to be covered for loss of income?
Vehicle 1 - Would you like glass replacement coverage?
Vehicle 1 - Is your car upgraded or have extra equipment?
Vehicle 1 - Special Instructions
Vehicle 1 - Which drivers will be using this vehicle?		Driver 1 Driver 2 Driver 3 Driver 4

Specialty Vehicle 1 - please fill out if applicable

Motorcycle
If motorcycle, years of experience
If motorcycle, how many CCs (engine size)
Stored in a locked facility?
Boat
Boat Motor Type
Boat Contruction Material
Boat Length
Boat Maximum Speed
Boat Trailer Value to be included
Motor Home
Motor Home Length
Is the motor home a converted bus or other vehicle
Used as a permanent residence?
Any business use?

Vehicle 2 Information
Vehicle 2 VIN (Vehicle Information Number)
Vehicle 2 Registered Vehicle Owner
Vehicle 2 Usage
Vehicle 2 Annual Mileage
Vehicle 2 Vehicle Type
Vehicle 2 Vehicle Year
Vehicle 2 Vehicle Make
Vehicle 2 Vehicle Model
Vehicle 2 Liability
Vehicle 2 Uninsured/Underinsured Motorist Coverage (UM/UIM)
Vehicle 2 Medical Coverage
Vehicle 2 Comprehensive Coverage
Vehicle 2 Collision Coverage
Vehicle 2 - Do you want towing services?
Vehicle 2 - Do you want car rental services?
Vehicle 2 - Do you want to be covered for loss of income?
Vehicle 2 - Would you like glass replacement coverage?
Vehicle 2 - Is your car upgraded or have extra equipment?
Vehicle 2 - Special Instructions
Vehicle 2 - Which drivers will be using this vehicle?		Driver 1 Driver 2 Driver 3 Driver 4

Specialty Vehicle 2 - please fill out if applicable

Motorcycle
If motorcycle, years of experience
If motorcycle, how many CCs (engine size)
Stored in a locked facility?
Boat
Boat Motor Type
Boat Contruction Material
Boat Length
Boat Maximum Speed
Boat Trailer Value to be included
Motor Home
Motor Home Length
Is the motor home a converted bus or other vehicle
Used as a permanent residence?
Any business use?

Vehicle 3 Information
Vehicle 3 VIN (Vehicle Information Number)
Vehicle 3 Registered Vehicle Owner
Vehicle 3 Usage
Vehicle 3 Annual Mileage
Vehicle 3 Vehicle Type
Vehicle 3 Vehicle Year
Vehicle 3 Vehicle Make
Vehicle 3 Vehicle Model
Vehicle 3 Liability
Vehicle 3 Uninsured/Underinsured Motorist Coverage (UM/UIM)
Vehicle 3 Medical Coverage
Vehicle 3 Comprehensive Coverage
Vehicle 3 Collision Coverage
Vehicle 3 - Do you want towing services?
Vehicle 3 - Do you want car rental services?
Vehicle 3 - Do you want to be covered for loss of income?
Vehicle 3 - Would you like glass replacement coverage?
Vehicle 3 - Is your car upgraded or have extra equipment?
Vehicle 3 - Special Instructions
Vehicle 3 - Which drivers will be using this vehicle?		Driver 1 Driver 2 Driver 3 Driver 4

Specialty Vehicle 3 - please fill out if applicable

Motorcycle
If motorcycle, years of experience
If motorcycle, how many CCs (engine size)
Stored in a locked facility?
Boat
Boat Motor Type
Boat Contruction Material
Boat Length
Boat Maximum Speed
Boat Trailer Value to be included
Motor Home
Motor Home Length
Is the motor home a converted bus or other vehicle
Used as a permanent residence?
Any business use?

Vehicle 4 Information
Vehicle 4 VIN (Vehicle Information Number)
Vehicle 4 Registered Vehicle Owner
Vehicle 4 Usage
Vehicle 4 Annual Mileage
Vehicle 4 Vehicle Type
Vehicle 4 Vehicle Year
Vehicle 4 Vehicle Make
Vehicle 4 Vehicle Model
Vehicle 4 Liability
Vehicle 4 Uninsured/Underinsured Motorist Coverage (UM/UIM)
Vehicle 4 Medical Coverage
Vehicle 4 Comprehensive Coverage
Vehicle 4 Collision Coverage
Vehicle 4 - Do you want towing services?
Vehicle 4 - Do you want car rental services?
Vehicle 4 - Do you want to be covered for loss of income?
Vehicle 4 - Would you like glass replacement coverage?
Vehicle 4 - Is your car upgraded or have extra equipment?
Vehicle 4 - Special Instructions
Vehicle 4 - Which drivers will be using this vehicle?		Driver 1 Driver 2 Driver 3 Driver 4
Please list any additional vehicle/driver information in the comment box at the bottom of this form (please specify which of the above vehicles' coverages you would like to match)

Specialty Vehicle 4 - please fill out if applicable

Motorcycle
If motorcycle, years of experience
If motorcycle, how many CCs (engine size)
Stored in a locked facility?
Boat
Boat Motor Type
Boat Contruction Material
Boat Length
Boat Maximum Speed
Boat Trailer Value to be included
Motor Home
Motor Home Length
Is the motor home a converted bus or other vehicle
Used as a permanent residence?
Any business use?

Health/Life
Which type(s) are you interested in?
If you want life insurance, which type?
If you want life insurance, how much?
If you want health insurance, which type(s)?
Do you have prior insurance?
If so, how long have you had it?
Current Carrier
Type of Coverage
Do you have any existing health conditions?
Are you self employed?
Do you smoke?
Are you over or underweight?

Home
Type
Garage Type
Type of insurance you want
Year Built
Distance from fire department
Distance from fire hydrant
Number of claims in the last five years
If you had claims, what was the payout and what type of claim?
insured value (cost to replace house excluding land)
Square feet (excluding basement and garage)
Basement percentage of ground floor
Special Concerns
Pool?
Trampoline?
Condition of property?
Cancelled by prior company?
If yes, why?
Breed of dog
Business in Home?

QUOTE REQUEST FORM Thank you for requesting a quote. In order to provide an accurate quote, we will need your Social Security number. Please call our secure voicemail at 434-977-5449 and provide the name and SSN # for each person that you are requesting a quote for.
First Name*
Last Name*
Date of Birth*
Street Address*
City*
State*
Zip*
Phone*
Fax
Email
Gender*		Female Male
I prefer to be contacted*
I prefer to pay
I prefer to pay by
Below you can fill out information for the auto, health/life, or home insurance. Please check the boxes below for the types of insurance you would like quoted and the form will expand to gather the appropriate information. Auto Health/Life Home

Other Coverages
We also offer many other kinds of specialized insurance including, but not limited to Workers Compensation, Equine, Truckers, Artisan Contractors, Commercial GL, Professional Liability, Restaurants, Office BOPs, Cargo and many types of bonds.
I would also be interested in a quote for the following coverages:
long term care
disability
commercial
umbrella
annuity
IRA
other

Comments:

QUOTE REQUEST FORM

Auto

Driver 1 Information

Driver 2 Information

Driver 3 Information

Driver 4 Information

Vehicle 1 Information

Specialty Vehicle 1

Vehicle 2 Information

Specialty Vehicle 2

Vehicle 3 Information

Specialty Vehicle 3

Vehicle 4 Information

Specialty Vehicle 4

Health/Life

Home

Other Coverages

Comments: