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Rufus Jackson Agency

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Name *

First

Last

Date of Birth *

Driver's License #/State Issued *

Additional Owner/Driver *

First

Last

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Date of Birth *

Driver's License#/State Issued *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone *

Email *

Are You a Homeowner? *

Yes No

Currently Insured - Car *

Yes No

Currently Insured - Home *

Yes No

Health Insurance? *

Yes No

If yes, Carrier and Policy #? *

Premium and Exp Date *

If yes, Carrier and Policy #? *

Premium and Exp Date *

Healthcare Provider *

Your House

Your Vehicles

Year Built *

Model Year *

Make/Manufacturer *

Occupancy Status *

Property Type *

Model Year *

Make/Manufacturer *

Total Living Sq Ft *

# of Stories *

# of Bedrooms *

Upgrades? *

Yes No

Roof - Year Upgraded *

Heating/Cooling - Year Upgraded *

# of Baths *

Do you have a wood burning stove? *

Yes No

Plumbing - Year Upgraded *

Electric - Year Upgraded *

Basement Type *

Garage Type *

Roof Type *

Exterior Wall *

Brick on frame Brick, Solid Shakes, Wood Siding, Aluminum Siding, Vinyl Siding, Clapboard Siding, Wood

Check all that apply

Interior Features *

Fireplace, Direct Fireplace, Gas Attic, Finished Sliding Glass Doors Hot Tub Jacuzzi

Select all that apply

Attached Structures *

Open Porch Screened Porch Enclosed Porch Wood Deck Redwood Deck

Select all that apply

Basement Finished *

Number of Cars *

Security System *

Partition Wall *

Block Drywall Drywall, textured Plaster

Select all that apply

Exterior Features *

Door, Atrium Window, Atrium Window, Bay Window, Bow Skylights, Small Skylights, Large

Select all that apply

Detached Structures *

Hot Tub/Jacuzzi Shed, Small (6' x 16') Shed, Medium (20' x 40') Shed, Large (30' x 50') Swimming Pool Above/Inground

Select all that apply

Model/Body Style *

VIN *

Model/Body Style *

VIN *

Additional Drivers *

Current Vehicle Liability Coverage

Vehicle 1 *

Vehicle 2 *

Comp *

Yes No

Comp *

Yes No

Collision *

Yes No

Collision *

Yes No

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What Our Clients Are Saying

Best Agent in town, saved me a ton of money monthly, actually, got twice the coverage for way less..... thank u soooooooooo much Rufus!"
- Jennifer Ledesma

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