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What type of Insurance are you looking for?
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Home
Auto
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Desired Effective Date
MM slash DD slash YYYY
Prior Insurance
Please tell us if you currently have auto insurance.
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No
Prior Insurance
Please list prior insurance company and effective dates.
Prior Insurance
If available, please upload a copy of your current declarations page.
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Accepted file types: pdf, png, jpg, , Max. file size: 2 GB, Max. files: 4.
List All Household Drivers
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Driver Full Name
Date of Birth (MM/DD/YYYY)
License Number
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List All Vehicles
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Year
Make & Model
VIN
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Bodily Injury & Property Damage
*
Bodily injury pays in the event you injure others in an accident and also provides for a legal defense if you are sued. Property damage pays for the damage you've caused to someone else's property.
Please Select
$25,000 / $50,000 / $25,000
$50,000 / $100,000 / $50,000
$100,000 / $300,000 / $100,000
$250,000 / $500,000 / $100,000
$500,000 / $500,000 / $100,000
$100,000 Combined Limit
$300,000 Combined Limit
$500,000 Combined Limit
Uninsured & Underinsured Motorist
*
Uninsured motorist coverage protects you in in the event you are injured by someone without any liability coverage. Underinsured motorist coverage protects you if they do not have sufficient coverage.
Please Select
$25,000 / $50,000
$50,000 / $100,000
$100,000 / $300,000
$250,000 / $500,000
$500,000 / $500,000
$100,000 Combined Limit
$300,000 Combined Limit
$500,000 Combined Limit
Stacking Option
*
Stacking your Uninsured and Underinsured Motorist coverages multiplies the coverage limit by the number of vehicles on the policy.
Yes
No
Tort Option
*
Full tort allows you to sue for monetary and non-monetary damages as a result of any accident. Limited tort means that you cannot sue for non-monetary damages (pain and suffering) unless you were seriously injured.
Full Tort
Limited Tort
Collision Deductible
*
Collision coverage pays to repair your car in the event you are responsible for the damage or involved in a hit and run. This is the amount you are responsible for paying before the insurance company pays.
Please Select
$1,000
$500
$250
$100
No Coverage
Comprehensive Deductible
*
Comprehensive (other than collision) coverage pays for losses to your car that are not due to a collision, such as theft, vandalism, glass breakage, hitting a deer, etc. This is the amount you are responsible for paying before the insurance company pays.
Please Select
$1,000
$500
$250
$100
No Coverage
Roadside Assistance
*
Roadside Assistance will provide towing service as well as roadside services such as a jump start, fuel delivery, flat tire change and lockout assistance.
Yes
No
Rental Reimbursement
*
Rental Reimbursement pays for you to rent a car if your car is off the road due to a covered loss. Per day / Per occurrence.
Please Select
No Coverage
$30 / $900
$40 / $1,200
$50 / $1,500
$75 / $2,250
$1,000 / $3,000
Medical Coverage
*
This covers medical expenses you may need to treat injuries resulting from an accident involving a vehicle.
Please Select
$5,000 (State Minimum)
$10,000
$25,000
$50,000
$100,000
$1,100,000
Wage Loss
*
This coverage pays your lost wages in the event you are unable to work due to injuries sustained in an auto accident. Per month / Per Occurrence
Please Select
$1,000 / $5,000
$1,000 / $15,000
$1,500 / $15,000
$1,500 / $25,000
$2,500 / $50,000
No Coverage
Funeral Benefit
*
This helps cover funeral costs in the event of death from an auto accident.
Please Select
$1,500
$2,500
No Coverage
Accidental Death
*
This pays in the event of a fatal accident.
Please Select
$5,000
$10,000
$25,000
No Coverage
Prior Accidents & Violations
*
Ride-Sharing & Delivery
*
Do you currently drive or intend to drive for Uber, Lyft, Grubhub, or other delivery services?
Yes
No
Billing
How do you intend to pay your auto insurance?
Please Select
Pay In Full
Monthly Installments
Not Sure Yet
Desired Policy Effective Date
MM slash DD slash YYYY
Date of Birth
*
MM slash DD slash YYYY
Policy Type
*
Homeowners
Condominium
Renters
Is this a new purchase?
*
Yes
No
Prior Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Prior Insurance
*
Please tell us if you currently have homeowners or renters insurance.
Yes
No
Prior Insurance
Please list prior insurance company and effective dates.
Prior Insurance
If available, please upload a copy of your current declarations page.
Drop files here or
Select files
Accepted file types: pdf, png, jpg, Max. file size: 2 GB, Max. files: 4.
Personal Liability
This pays if you or another household resident injures someone or damages their property
Please Select
$300,000
$500,000
$1,000,000
Personal Property
*
This coverage pays to replace your wardrobe, electronics, furniture, and all other belongings. Let us know if you need assistance estimating the total value of your belongings.
Medical Payments
This is a good will offering in the event you are involved with someone, other than an insured, being injured. It will pay their related medical bills.
Please Select
$1,000
$5,000
$10,000
Deductible
The amount you are responsible for in the event of a claim. Higher deductibles help lower premiums.
Please Select
$500
$1,000
$2,500
$5,000
$10,000
$25,000
Additional Endorsements
Power Surge (Special Personal Property)
ID Theft
Back Up of Water and Sewer
Buried Utility Line
Roof & Siding Match
Personal Injury
Loss Assessment
Earthquake
Sinkhole Collapse
Valuable Items
*
Do you have any valuable items you want to insure? This may include jewelry, furs, computers, etc.
Yes
No
Valuable Items
*
In-Home Business
*
Do you conduct business at home? (i.e. hair salon, consulting, etc.)
Yes
No
In-Home Business
*
Dogs In Household
*
Do you own any dogs?
Yes
No
Dogs In Household
*
Please list breed(s)
Year Roof Replaced
*
Heating Type
*
Please Select
Gas
Oil
Electric
Other
Finished Basement?
*
Please Select
No
Partially Finished
Fully Finished
Additional Comments
Umbrella Liability Amount
*
Umbrellas can be purchased in million dollar increments.
Please Select
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
$7,000,000
$8,000,000
$9,000,000
$10,000,000
Additional Exposures
One Last Thing!
How did you hear about Frees Insurance?
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Google Search
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Referred by Friend or Family
Other
Friend or Family
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How did you hear about Frees Insurance?
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