North Star Insurance Services, LLC - Insuring your future

Agent Information Name of the agent whom you were referred to or sent you a letter:

Personal Information First Name:   Last Name:   Date of Birth: Spouse First Name:   Last Name:   Date of Birth: Home Address: City:   State:   Zip: Cell Phone:   Email Address:

Current Homeowner's Information Please provide as much information as possible. The more you give, the more accurate the results will be. Current Dwelling Coverage: $   Style: -- Please Select --1 Story1 1/2 Story2 StorySplit Level Year built?:   Sq. Footage Above Ground (do not include basement): Basement: Yes No   % Finished: -- Please Select --102030405060708090100 Number of bathrooms: -- Please Select --11 1/222 1/233 1/244 1/2   Exterior: -- Please Select --WoodBrickVinylCement BoardAluminumOther Garage: -- Please Select --1 Car2 Car3 Car4 Car   Garage Type: -- Please Select --AttachedDetached Outbuilding: Length: ft.   Width: ft.     Deck on Home? Yes No Pool: Yes No       Diving Board / Slide: Yes No       Fenced: Yes No Fireplace: Yes No       Type: Natural Gas Logs Dogs: -- Please Select --None123> 3     Breed:

Homeowner's Discounts Occupation:     Spouse Occupation: Education: -- Please Select --High SchoolSome CollegeAssociate DegreeBachelor DegreeMaster DegreeDoctorate Degree      Spouse Education:   -- Please Select --High SchoolSome CollegeAssociate DegreeBachelor DegreeMaster DegreeDoctorate Degree Age Of Roof: years.       Central Alarm: Yes No Current Annual Premium: $       Current Insurance Carrier:

Additional Drivers Please list any additional drivers to be insured First Name Last Name Date of Birth Good Student (3.0+ GPA) Yes No Add Another Driver Yes No Add Another Driver Yes No Add Another Driver Yes No Add Another Driver Yes No

Automobile Information Please list Automobile(s) to be insured Year Make Model Compre- hensive Collision Liability Only Road Service Full Glass Coverage Yes Yes Yes Yes Yes Add Another Car Yes Yes Yes Yes Yes Add Another Car Yes Yes Yes Yes Yes Add Another Car Yes Yes Yes Yes Yes Add Another Car Yes Yes Yes Yes Yes

Coverage Information Please select Coverage amounts and Deductibles for each car Automobile Comprehensive Deductible Collision Deductible Liability Amount -- Select --$100$250$500$1,000   -- Select --$250$500$1,000   -- Select --$50,000/100,000$100,000/300,000$250,000/500,000$500,000/500,000   -- Select --$100$250$500$1,000   -- Select --$250$500$1,000   -- Select --$50,000/100,000$100,000/300,000$250,000/500,000$500,000/500,000   -- Select --$100$250$500$1,000   -- Select --$250$500$1,000   -- Select --$50,000/100,000$100,000/300,000$250,000/500,000$500,000/500,000   -- Select --$100$250$500$1,000   -- Select --$250$500$1,000   -- Select --$50,000/100,000$100,000/300,000$250,000/500,000$500,000/500,000   -- Select --$100$250$500$1,000   -- Select --$250$500$1,000   -- Select --$50,000/100,000$100,000/300,000$250,000/500,000$500,000/500,000

Current Health Provider Please make a selection below Private Insurer       Medicare/Medicaid Parts A/B       No Current Coverage

Automobile Discounts Defensive Driving Course Current Six Month Premium Current Insurance Carrier Yes No $

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