Gordon Insurance

Name
*


First
Last
*


Last
Phone
*


Email
*


What type of Insurance Quote are you interested in? (Select all that apply)
Auto Insurance
Business Insurance
Condominium or Multifamily Insurance
Home Insurance
Landlord Policy
Renters Insurance
Workers Compensation
Is there anything else that you’d like us to know before contacting you?


File Upload



Drop a file here or click to upload
Choose File

Maximum file size: 104.86MB

Please attach files that you would like us to have


If you are human, leave this field blank.


Submit

First Name
*


Last Name
*


Phone
*


Email


Address
*

Birthday
*


Driver’s License Number (Optional)


Required to get a more accurate Auto Quote
State
*

AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
Previous Residence
*
Yes
No
Have you lived somewhere else in the previous 6 months?

Previous Address

Previous Address
*

Own or Rent your residence?
*
Own your residence
Rent your residence
Any incidents in the previous 3 years?
*
Yes
No

Incident Information

Approximate date
*


At Fault or Not At Fault
*

At Fault IncidentNot At Fault Incident
  Add
Remove
Current Insurance Status
*

Currently InsuredNot currently insured
Current Insurance Carrier
*


Length of time with current Carrier
*

Less than 1 yearLess than 2 yearsLess than 3 yearsGreater than 3 years
Has any company declined, cancelled or refused to renew your auto insurance policy for you or any listed driver in the last 3 years?
*
Yes
No
Are there additional drivers?
Yes, additional drivers
No, no additional drivers

Additional Driver Information

First Name
*


First Name
Last Name
*


Last Name
Birthday
*


Relationship to named Insured
*

SpouseChildOther
Drivers License Number (Optional)


Driver License State
*

AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
  Add
Remove

Vehicle Information

To get a more accurate proposal a VIN number for Vehicle would be required.


Use Vin Number or Type in Make/Model/Year
*
Vin Number
Make / Model / Year
Vin Number
*


Please enter your VIN number
Select Year
*



1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Select Make
*



Select Model



  Add
Remove
Would you like to receive a quote for your home (often there is a discount to bundle)?
Yes
No
Would you like to receive a quote for a renters policy (often there is a discount to bundle)?
Yes
No

Residence Information

Has your homeowners insurance been cancelled/declined/nonrenewed in the last 3 years?
*
Yes
No
Current Insurance Status
*

Currently InsuredNot currently insured
Current Insurance Carrier
*


Approximately, when was the roof last replaced?
*


Does your property have a sprinkler system?
Yes
No
Square Footage (Not including Basement)


Finished Basement Square Footage (Approximate)


Number of Full Bathrooms


Number of Half Bathrooms


Home Renovations:


Please note any renovations that have taken place
File Upload (Optional)



Drop a file here or click to upload
Choose File

Maximum file size: 104.86MB

Potential Documents to Upload (Driver’s License, Insurance Card, Current Insurance Policy)
I acknowledge that Gordon Insurance will run a report in order to collect additional information in order to get the most accurate insurance proposal


If you are human, leave this field blank.


Submit

First Name
*


Last Name
*


Phone
*


Email


Birthday
*


Address
*

Previous Residence
*
Yes
No
Have you lived somewhere else in the previous 6 months?

Previous Address

Previous Address
*

Residence Information

Has your homeowners insurance been cancelled/declined/nonrenewed in the last 3 years?
*
Yes
No
Current Insurance Status
*

Currently InsuredNot currently insured
Current Insurance Carrier
*


Approximately, when was the roof last replaced?
*


Does your property have a sprinkler system?
Yes
No
Square Footage (Not including Basement)


Finished Basement Square Footage (Approximate)


Number of Full Bathrooms


Number of Half Bathrooms


Home Renovations:


Please note any renovations that have taken place
Would you like to receive a quote for your vehicles (often there is a discount to bundle)?
Yes
No

Driver’s License Number (Optional)


Required to get a more accurate Auto Quote
State
*

AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
Any incidents in the previous 3 years?
*
Yes
No

Incident Information

Approximate date
*


At Fault or Not At Fault
*

At Fault IncidentNot At Fault Incident
  Add
Remove

Current Insurance Status
*

Currently InsuredNot currently insured
Current Insurance Carrier
*


Length of time with current Carrier
*

Less than 1 yearLess than 2 yearsLess than 3 yearsGreater than 3 years
Has any company declined, cancelled or refused to renew your auto insurance policy for you or any listed driver in the last 3 years?
*
Yes
No
Are there additional drivers?
Yes, additional drivers
No, no additional drivers

Additional Driver Information

First Name
*


First Name
Last Name
*


Last Name
Birthday
*


Relationship to named Insured
*

SpouseChildOther
License Number (Optional)


Driver’s License State
*

AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
  Add
Remove

Vehicle Information

To get a more accurate proposal a VIN number for Vehicle would be required.


Use Vin Number or Type in Make/Model/Year
*
Vin Number
Make / Model / Year
Vin Number
*


Please enter your VIN number
Select Year
*



1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Select Make
*



Select Model



  Add
Remove
File Upload (Optional)



Drop a file here or click to upload
Choose File

Maximum file size: 104.86MB

Potential Documents to Upload (Driver’s License, Insurance Card, Current Insurance Policy)
*
I acknowledge that Gordon Insurance will run a report in order to collect additional information in order to get the most accurate insurance proposal


If you are human, leave this field blank.


Submit

First Name
*


Last Name
*


Property Ownership Name (If Different)


Phone
*


Email


Mailing Address (Not your Rental Property Address)
*

Rental Property Information (Click Add at the bottom to include additional Properties)

Rental Property Address
*

Current Insurance Status
*

Currently InsuredNot currently insured
Current Insurance Carrier
*


Has your rental insurance policy been cancelled/declined/nonrenewed in the last 3 years?
*
Yes
No
Have there been any claims for this property in the past 3 years?
*
Yes
No
Briefly describe the claim
*


Briefly describe the claim and include approximate dates
Approximately, when was the roof last replaced?
*


Does your property have a sprinkler system?
*
Yes
No
Square Footage (Not including Basement)


Finished Basement Square Footage (Approximate)


Number of Full Bathrooms


Number of Half Bathrooms


Is there a Fire Place?
*
Yes
No
What type of Fire place is it?
*

GasWood Burning
Home Renovations:


Please note any renovations that have taken place
Add
Remove
File Upload (Optional)



Drop a file here or click to upload
Choose File

Maximum file size: 104.86MB

Potential Documents to Upload Current Insurance Policy)
I acknowledge that Gordon Insurance will run a report in order to collect additional information in order to get the most accurate insurance proposal
Dropdown

Option 1


If you are human, leave this field blank.


Submit

Your Name
*


First
Last Name
*


Last
Phone
*


Email
*


Business Name
*


Federal Tax ID (optional)


Not required at this time, but we will need it at a later time
Address
*

What type of coverage are you seeking? Select all that apply
*
General Liability
Business Owners Policy (BOP) or Commercial Policy Package (CPP)
Commercial Property
Commercial Auto
Workers Compensation
Years in Business
*

– Please select –Less than 1 Year12345678910+
How many years has the business been operating?
Years of experience in the Industry?
*

– Please Select –0 – 1 Years2-3 Years4-10 Years10+ Years
How many years of experience do you have in the industry?
Number of Employees
*


Please enter the total number of employees (Including part time and yourself)
Projected Annual Revenue
*

– Please Select –Under $100,000$100,000 – $200,000$200,001 – $300,000$300,001 – $500,000$500,001 – $750,000$750,001 – $1,000,000$1,000,000 +
What is the approximate Projected Annual Revenue from your business
Total Value of Personal Property


Brief Description of the business
*


I.E : I am general contractor that renovates homes, HVAC company, run a marketing company, etc..
Would you like to fill out the Worker Compensation questions now?
Yes
No

Workers Compensation Questions

Current Carrier (If any)


List any Class Codes from Current or Prior Policies? (optional)


If you know the class codes, please enter them here
Do You Prefer Owners to be excluded from the Policy?
*
Yes, Exclude the owners
No, Include the owners
Owners Salary
*


Please enter in the total owners salary to be excluded
Have You Had Any Claims or Coverage Lapses Over Last 3 Years?
*
Yes
No
Please include any information on the claim or coverage lapse


Would you like to fill out the Commercial Auto questions now?
*
Yes
No
Provide Driver information now?
*
Yes
No

Driver Information

First Name
*


Last Name
*


Birthday (Optional)


Required for an accurate proposal
Drivers License Number (Optional)


Required for an accurate proposal
Drivers License Issuing State
*

AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
  Add
Remove
Provide Vehicle information now?
*
Yes
No

Vehicle Information

To get a more accurate proposal a VIN number for Vehicle would be required.


Use Vin Number or Type in Make/Model/Year
*
Vin Number
Make/Model/Year
Vin Number
*


Please enter your VIN number
Select Year
*



1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Select Make
*



Select Model



  Add
Remove
Is there anything else that you’d like us to know before contacting you?


File Upload



Drop a file here or click to upload
Choose File

Maximum file size: 104.86MB

Please attach files that you would like us to have
I acknowledge that Gordon Insurance will run a report in order to collect additional information in order to get the most accurate insurance proposal


If you are human, leave this field blank.


Submit

Your Name
*


First
Last Name
*


Last
Phone
*


Email
*


Business Name
*


Address
*

Number of Employees
*


Please enter the total number of employees (Including part time and yourself)
Business Type
*

– Please Select –IndividualPartnershipLLCS – CorpC – CorpOther
Business Type
Annual Payroll (Including Owners)


Years in Business
*

– Please select –Less than 1 Year12345678910+
How many years has the business been operating?
Years of experience in the Industry?
*

– Please Select –0 – 1 Years2-3 Years4-10 Years10+ Years
How many years of experience do you have in the industry?
Brief Description of the business
*


I.E : I am general contractor that renovates homes, HVAC company, run a marketing company, etc..
Current Carrier (If any)


List any Class Codes from Current or Prior Policies?


If you know the class codes, please enter them here
Do You Prefer Owners to be excluded from the Policy?
*
Yes, Exclude the owners
No, Include the owners
Owners Salary
*


Please enter in the total owners salary to be excluded
Have You Had Any Claims or Coverage Lapses Over Last 3 Years?
*
Yes
No
Please include any information on the claim or coverage lapse
*


Is there anything else that you’d like us to know before contacting you?


File Upload



Drop a file here or click to upload
Choose File

Maximum file size: 104.86MB

Please attach files that you would like us to have including existing or previous policy
I acknowledge that Gordon Insurance will run a report in order to collect additional information in order to get the most accurate insurance proposal


If you are human, leave this field blank.


Submit