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Jen Johnson
2023-08-06T00:14:30-04:00
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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
No
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
- Select 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
State
ZIP Code
Current Address
*
Same as Mailing Address
Street Address
Address Line 2
City
- Select 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
State
ZIP Code
Primary Applicant
Date of Birth
*
Month
Day
Year
Gender
*
- Select -
Female
Male
Prefer not to answer
Drivers License State
*
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License Number
Motorcycle Endorsement?
No
Yes
Marital Status
- Select -
Single
Married
Domestic Partner (Unmarried)
Widowed
Separated
Divorced
Fiance or Fiancee
Other
Unknown
Civil Union / Registered Domestic Partner
Occupation
Education Level
- Select -
No High School Diploma or GED
High School
Associate Degree
Bachelor's Degree
Graduate or Professional Degree
Some College
Other
Prefer Not to Answer
Is there a Co-Applicant?
No
Yes
Co-Applicant
Co-Insured Name
*
First
Last
Co-Insured Date of Birth
*
Month
Day
Year
Co-Insured Gender
*
- Select -
Female
Male
Prefer not to answer
Co-Insured Drivers License State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Co-Insured Drivers License Number
Co-Insured Motorcycle Endorsement?
No
Yes
Co-Insured Email
Co-Insured Phone
Co-Insured Occupation
Co-Insured Education Level
- Select -
No High School Diploma or GED
High School
Associate Degree
Bachelor's Degree
Graduate or Professional Degree
Some College
Other
Prefer Not to Answer
Property Information
Property Address
*
Same as Current Address
Street Address
Address Line 2
City
- Select 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
State
ZIP Code
Type of Home
Single Family
Condo
Manufactured
Townhome
Duplex
Triplex
4-Plex
Apartment
Primary Use For Home
Primary Residence
Secondary Residence
Short-Term Vacation Rental (VRBO, AirBnB, etc.)
Short-Term Rental (Less than 6 months)
Long-Term Rental (Greater than 6 months)
Is property titled in a name Other Than your personal name(s)?
*
Example: Trust, LLC, Corporation, Partnership, etc.
No
Yes
Name on Title of Property
*
Is this a New Purchase?
*
No
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
Select files
Accepted file types: pdf, Max. file size: 12 MB, Max. files: 5.
Will there be a Mortgage?
*
No
Yes
Have Dogs?
No
Yes
Breed(s) of Dog(s)
Reported Claims on any property owned in the last 5 years?
*
- Select -
0 Claims
1 Claim
2 or More Claims
Have you had any insurance lapse (30 days or more), cancel, or non-renew in the last 3 years?
*
No
Yes
No prior insurance
Home Information
Year Home Built
*
Has there been any updates to the Roof, Plumbing, Heating, or Electrical?
No
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?
No
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
Select files
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?
No
Yes
List of Scheduled Items
Item Description
Item Value ($)
Do you have an appraisal
Add
Remove
Additional Drivers
Are there additional drivers in your household?
No
Yes
Additional Driver 1
1. Driver Name
*
First
Last
1. Driver Date of Birth
*
Month
Day
Year
1. Gender
*
- Select -
Female
Male
Prefer not to answer
1. Driver License #
1. Drivers License State
*
- Select State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Add 2nd Driver
Add Another Driver
Additional Driver 2
2. Driver Name
*
First
Last
2. Driver Date of Birth
*
Month
Day
Year
2. Gender
*
- Select -
Female
Male
Prefer not to answer
2. Driver License #
2. Drivers License State
*
- Select State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Add 3rd Driver
Add Another Driver
Additional Driver 3
3. Driver Name
*
First
Last
3. Driver Date of Birth
*
Month
Day
Year
3. Gender
*
- Select -
Female
Male
Prefer not to answer
3. Driver License #
3. Drivers License State
*
- Select State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Add 4th Driver
Add Another Driver
Additional Driver 4
4. Driver Name
*
First
Last
4. Driver Date of Birth
*
Month
Day
Year
4. Gender
*
- Select -
Female
Male
Prefer not to answer
4. Driver License #
4. Drivers License State
*
- Select State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Vehicle 1
1. VIN
1. Year
*
1. Make
*
1. Model
*
1. Estimated Annual Miles
1. Primary Use
Pleasure
To/From Work
Business
1. Ownership
Own
Lease
1. Vehicle Financed
No
Yes
1. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
1. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
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
Pleasure
To/From Work
Business
2. Ownership
Own
Lease
2. Vehicle Financed
No
Yes
2. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
2. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
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
Pleasure
To/From Work
Business
3. Ownership
Own
Lease
3. Vehicle Financed
No
Yes
3. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
3. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
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
Pleasure
To/From Work
Business
4. Ownership
Own
Lease
4. Vehicle Financed
No
Yes
4. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
4. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
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
Pleasure
To/From Work
Business
5. Ownership
Own
Lease
5. Vehicle Financed
No
Yes
5. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
5. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
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
Pleasure
To/From Work
Business
6. Ownership
Own
Lease
6. Vehicle Financed
No
Yes
6. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
6. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
6. Vehicle is used for
*
Rideshare/TNC (Uber, DoorDash,Turo etc.)
Delivery (excluding Rideshare)
None
Special Motorcycle Coverages
Enhanced Injury Protection
Yes
No
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
$1 - $3,000
$3,001 - $4,000
$4,001 - $5,000
$5,001 - $6,000
$6,001 - $7,000
$7,001 - $10,000
$10,001 - $15,000
$15,001 - $20,000
$20,001 - $25,000
$25,001 - $30,000
Safety & Riding Apparel
$1 - $500
$501 - $1,000
$1,001 - $1,500
$1,501 - $2,000
$2,001 - $2,500
$2,501 - $3,000
Transport Trailer Coverage?
No
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
- Select -
Fiberglass
Aluminum
Wood
Inflatable
Steel
Other
Number of Motors
*
1
2
3+
Propulsion Type
*
- Select -
Inboard
Outboard
Inboard / Outboard
Jet
Max Horsepower
*
Max Speed
Current Value
Fishing Equipment Coverage
None
$1,000
$2,500
$5,000
$10,000
Insure the Trailer?
Yes
No
Umbrella Coverage Information
Number of Properties
1
2
3
4
5
6
7
8
9
10
Number of Vehicles
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Number of Drivers
1
2
3
4
5
6
7
8
9
10
Any drivers under age 25?
No
Yes
Any drivers over age 75?
No
Yes
Liability Limit
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$10,000,000
$20,000,000
Greater than $20,000,000
Wrapping Up
Any Claims in the Past Three (3) Years?
*
No
Yes
Please describe past claims
*
Any prior flood losses for your property?
No
Yes
Do you need any SR-22 filings?
*
No
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
Select files
Max. file size: 12 MB.
Would you like a quote from a specific agent?
Jen Johnson
Amanda Boge
Trevor Johnson
Sarah Fenn
Krystyna Best
Jordan Driggers
Ruth Villanueva
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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