"*" indicates required fields

Thank you for your interest in receiving a quote from My Florida Insurance. This form should only take about 5-10 minutes to complete. Don't worry if you don't have everything. You can always click the "Save and continue later" button below. We'll email you a private link to pick up where you left off.

Types of Insurance*

Home

Motorcycle

Auto

Boat

Umbrella

Landlord Rental Property

Flood

Renters

Life

Date Policies Should Start*

MM slash DD slash YYYY

Name*

First Last

Email*

Phone*

Can we text you?*

Yes

Consent is not required as a condition of purchase. Message frequency will vary. Message and data rates may apply. Reply HELP for help or STOP to cancel. Privacy Policy.

How were you referred to us?*

Current Address

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Current Address*

Same as Mailing Address

Street Address Address Line 2 City State ZIP Code

Primary Applicant

Date of Birth*

Month

Day

Year

Gender*

Drivers License State*

Drivers License Number

Motorcycle Endorsement?

Yes

Marital Status

Occupation

Education Level

Is there a Co-Applicant?

Yes

Co-Applicant

Co-Insured Name*

First Last

Co-Insured Date of Birth*

Month

Day

Year

Co-Insured Gender*

Co-Insured Drivers License State

Co-Insured Drivers License Number

Co-Insured Motorcycle Endorsement?

Yes

Co-Insured Email

Co-Insured Phone

Co-Insured Occupation

Co-Insured Education Level

Property Information

Property Address*

Same as Current Address

Street Address Address Line 2 City State ZIP Code

Type of Home

Primary Use For Home

Is property titled in a name Other Than your personal name(s)?*

Example: Trust, LLC, Corporation, Partnership, etc.

Yes

Name on Title of Property*

Is this a New Purchase?*

Yes

Purchase Date*

MM slash DD slash YYYY

Purchase Price

Name of current home insurance carrier*

Why we need this: We represent many different insurance companies and we don't want to quote your insurance with the same carrier.

Current Homeowners Policy Upload

You may upload up to 5 policy documents. Only .pdf file type accepted.

Drop files here or

Accepted file types: pdf, Max. file size: 12 MB, Max. files: 5.

Will there be a Mortgage?*

Yes

Have Dogs?

Yes

Breed(s) of Dog(s)

Reported Claims on any property owned in the last 5 years?*

Have you had any insurance lapse (30 days or more), cancel, or non-renew in the last 3 years?*

Yes

No prior insurance

Home Information

Year Home Built*

Has there been any updates to the Roof, Plumbing, Heating, or Electrical?

Yes

Unsure

Roof Update Year

Plumbing Update Year

Heating Update Year

Electrical Update Year

Age of Water Heater

How many years old is the water heater? If you don't know, enter Unknown.

Solar Panels?

Yes

Number of Solar Panels

Value of Solar Panels

The following discounts are available. Please check all that apply.

Central Station Fire Alarm

Central Station Burglar Alarm

Water Leak Sensors

Home Security System (Cameras, RING, etc.)

HVAC Maintenance Contract

Please let us know if the property has any unique features

Examples: elevator, backup generator, water shut off monitoring, etc.

Photos of Home (Optional)

If you would like to attach any pictures of your home inside and/or outside, please do so here.

Drop files here or

Max. file size: 3 MB, Max. files: 6.

Scheduled Items

Most home insurance policies allow you to schedule valuable items to your policy such as jewelry, fine art, firearms, antiques, bikes, cameras, certain electronics, collectibles, musical instruments, silverware, etc. If you would like to include any of these items, please do so below. If an item is ineligible for scheduling to your policy we will let you know.

Do you have any items you would like to schedule to your policy?

Yes

List of Scheduled Items

Item Description

Item Value ($)

Do you have an appraisal

Additional Drivers

Are there additional drivers in your household?

Yes

Additional Driver 1

1. Driver Name*

First Last

1. Driver Date of Birth*

Month

Day

Year

1. Gender*

1. Driver License #

1. Drivers License State*

Add 2nd Driver

Add Another Driver

Additional Driver 2

2. Driver Name*

First Last

2. Driver Date of Birth*

Month

Day

Year

2. Gender*

2. Driver License #

2. Drivers License State*

Add 3rd Driver

Add Another Driver

Additional Driver 3

3. Driver Name*

First Last

3. Driver Date of Birth*

Month

Day

Year

3. Gender*

3. Driver License #

3. Drivers License State*

Add 4th Driver

Add Another Driver

Additional Driver 4

4. Driver Name*

First Last

4. Driver Date of Birth*

Month

Day

Year

4. Gender*

4. Driver License #

4. Drivers License State*

Vehicle 1

1. VIN

1. Year*

1. Make*

1. Model*

1. Estimated Annual Miles

1. Primary Use

1. Ownership

Own

Lease

1. Vehicle Financed

Yes

1. Preferred COMPREHENSIVE Deductible*

1. Preferred COLLISION Deductible*

1. Vehicle is used for*

Rideshare/TNC (Uber, DoorDash,Turo etc.)

Delivery (excluding Rideshare)

None

Add 2nd Vehicle

Add a Vehicle

Vehicle 2

2. VIN

2. Year*

2. Make*

2. Model*

2. Estimated Annual Miles

2. Primary Use

2. Ownership

Own

Lease

2. Vehicle Financed

Yes

2. Preferred COMPREHENSIVE Deductible*

2. Preferred COLLISION Deductible*

2. Vehicle is used for*

Rideshare/TNC (Uber, DoorDash,Turo etc.)

Delivery (excluding Rideshare)

None

Add 3rd Vehicle

Add a Vehicle

Vehicle 3

3. VIN

3. Year*

3. Make*

3. Model*

3. Estimated Annual Miles

3. Primary Use

3. Ownership

Own

Lease

3. Vehicle Financed

Yes

3. Preferred COMPREHENSIVE Deductible*

3. Preferred COLLISION Deductible*

3. Vehicle is used for*

Rideshare/TNC (Uber, DoorDash,Turo etc.)

Delivery (excluding Rideshare)

None

Add 4th Vehicle

Add a Vehicle

Vehicle 4

4. VIN

4. Year*

4. Make*

4. Model*

4. Estimated Annual Miles

4. Primary Use

4. Ownership

Own

Lease

4. Vehicle Financed

Yes

4. Preferred COMPREHENSIVE Deductible*

4. Preferred COLLISION Deductible*

4. Vehicle is used for*

Rideshare/TNC (Uber, DoorDash,Turo etc.)

Delivery (excluding Rideshare)

None

Add 5th Vehicle

Add a Vehicle

Vehicle 5

5. VIN

5. Year*

5. Make*

5. Model*

5. Estimated Annual Miles

5. Primary Use

5. Ownership

Own

Lease

5. Vehicle Financed

Yes

5. Preferred COMPREHENSIVE Deductible*

5. Preferred COLLISION Deductible*

5. Vehicle is used for*

Rideshare/TNC (Uber, DoorDash,Turo etc.)

Delivery (excluding Rideshare)

None

Add 6th Vehicle

Add a Vehicle

Vehicle 6

6. VIN

6. Year*

6. Make*

6. Model*

6. Annual Miles Driven

6. Primary Use

6. Ownership

Own

Lease

6. Vehicle Financed

Yes

6. Preferred COMPREHENSIVE Deductible*

6. Preferred COLLISION Deductible*

6. Vehicle is used for*

Rideshare/TNC (Uber, DoorDash,Turo etc.)

Delivery (excluding Rideshare)

None

Special Motorcycle Coverages

Enhanced Injury Protection

Yes

Physical Damage

Actual Cash Value

None - Liability Only

Roadside Assistance

None

Roadside

Roadside w/ Trip Interruption

Carried Contents

None

$1,000

$2,000

$3,000

Accessories Coverage

Safety & Riding Apparel

Transport Trailer Coverage?

Yes

Trailer Value

Boat Information

Serial Number*

Year*

Make*

Model*

Boat Registration Number

This is the ID number assigned to your boat by the state.

Hull Material

Number of Motors*

Propulsion Type*

Max Horsepower*

Max Speed

Current Value

Fishing Equipment Coverage

Insure the Trailer?

Yes

Umbrella Coverage Information

Number of Properties

Number of Vehicles

Number of Drivers

Any drivers under age 25?

Yes

Any drivers over age 75?

Yes

Liability Limit

Wrapping Up

Any Claims in the Past Three (3) Years?*

Yes

Please describe past claims*

Any prior flood losses for your property?

Yes

Do you need any SR-22 filings?*

Yes

Name of prior auto insurance company*

Enter None if no prior insurance.

Additional Comments

Attach Documents, Images, or Other Files

Drop files here or

Max. file size: 12 MB.

Would you like a quote from a specific agent?

How were you referred to us?

Consent*

Like most insurance agencies, we use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.

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Current Address

Primary Applicant

Co-Applicant

Property Information

Home Information

Scheduled Items

Additional Drivers

Additional Driver 1

Additional Driver 2

Additional Driver 3

Additional Driver 4

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

Special Motorcycle Coverages

Boat Information

Umbrella Coverage Information

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Current Address

Primary Applicant

Co-Applicant

Property Information

Home Information

Scheduled Items

Additional Drivers

Additional Driver 1

Additional Driver 2

Additional Driver 3

Additional Driver 4

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

Special Motorcycle Coverages

Boat Information

Umbrella Coverage Information

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