May 20, 2025 | The Southern Agency

Business Information

Federal ID Number

Address

Address Line 1

City

State

Zip Code

Owner(s) Owner Business

Business Contact

First

Last

Phone Number

Position

Business Operations

Desired Policy Start Date

Additional Comments/Requests

Name (feet) Life

Name

First

Last

Phone Number

Address

Address Line 1

City

State

Zip Code

Date of Birth

Tell us about your health & lifestyle.

Height (feet)

Height (inches)

Weight (pounds)

Has a biological parent or sibling been diagnosed with cancer, diabetes, or heart disease before the age of 60?

Have you used any nicotine or tobacco products in the last 3 years?

Amount of Life Insurance Requested ($)

Additional Comments/Requests

Name

First

Last

Phone Number

Address

Address Line 1

City

State

Zip Code

Date of Birth

Occupation

Marital Status

I would like an auto insurance quote!

Note: Bundling your auto and home insurance policies is often the most economical.

Drivers

Driver Name

Date of Birth

License State

License Number

Vehicles

Year

Make/Model

VIN #

Lienholder Name (if applicable)

Do you have any other vehicles (e.g. boat, ATV, RV, golf cart) to insure?

Other Vehicles

Year

Make/Model

VIN #

Lienholder Name (if applicable)

Have you had any automobile insurance claims or MVR violations within the past 5 years?

Auto Claims/MVR Violations (within past 5 years)

Date of Incident

Incident Description

Claim/Loss Amount

I would like an home insurance quote!

Note: Bundling your auto and home insurance policies is often the most economical.

Ownership Information

Closing Date

Do you have a mortgage on your home?

Is your home in escrow?

Monitoring System Information

Does your home have a central alarm system?

Does your home have a water alarm, lightning detector, or gas detector?

Water Alarm
Lightning Detector
Gas Detector

Home Details

Year of Construction

Square Footage

Construction Type (e.g. 1 story, 2 story, split level)

Build Type (e.g. frame, masonry, veneer, log)

# Baths

Garage Size (# Cars)

Exterior Siding

Porches/Decks

Roof Material

Age of HVAC System

Age of Roof

Flooring Type

Foundation

Outbuildings

Do you have a fireplace/wood stove?

Do you have a pool/hot tub?

Do you operate a business from home?

Do you have pets?

Do you have any valuable personal articles to cover?

Have you had any home/property claims in the past 5 years?

Describe fireplace/wood stove type.

Is your pool/hot tub fenced and gated?

Garage frame, Roof

List pet type(s) and breed(s).

Valuable Personal Articles

Item Description

Item Value

Claims History

Date of Incident

Incident Description

Claim/Loss Amount

1-800-777-1TSA (1-800-777-1872)

Insights that protect.
Knowledge that empowers.

Equipping you with practical guidance. insurance trends. industry developments.

FEATURED INSIGHTS

The Future of Insurance: Trends to Watch in the Coming Years

Skyrocketing Business Insurance Premiums in Georgia: Why It Happened — and How 2025 Tort Reforms Are Turning the Tide

Workers’ Compensation for Contractors: How to Stay Compliant

How Proactive Communication Can Save Your Business from Insurance Pitfalls

ALL INSIGHTS

The Future of Insurance: Trends to Watch in the Coming Years

Skyrocketing Business Insurance Premiums in Georgia: Why It Happened — and How 2025 Tort Reforms Are Turning the Tide

Workers’ Compensation for Contractors: How to Stay Compliant

How Proactive Communication Can Save Your Business from Insurance Pitfalls

Protecting Your Business from Employee-Related Claims

How Business Interruption Insurance Can Keep You Afloat During a Crisis

Unlocking the Best Rates: How Independent Agencies Offer More Personalized Insurance Options

Unveiling the Myths: What “Full Coverage” Auto Insurance Really Means for Drivers

Common Insurance Mistakes Small Business Owners Make (and How to Avoid Them)

Tell us about your health & lifestyle.

Drivers

Vehicles

Other Vehicles

Auto Claims/MVR Violations (within past 5 years)

Ownership Information

Mortgage Information

Monitoring System Information

Home Details

Valuable Personal Articles

Claims History

1-800-777-1TSA (1-800-777-1872)

Insights that protect.Knowledge that empowers.

Equipping you with practical guidance. insurance trends. industry developments.

FEATURED INSIGHTS

The Future of Insurance: Trends to Watch in the Coming Years

Skyrocketing Business Insurance Premiums in Georgia: Why It Happened — and How 2025 Tort Reforms Are Turning the Tide

Workers’ Compensation for Contractors: How to Stay Compliant

How Proactive Communication Can Save Your Business from Insurance Pitfalls

ALL INSIGHTS

The Future of Insurance: Trends to Watch in the Coming Years

Skyrocketing Business Insurance Premiums in Georgia: Why It Happened — and How 2025 Tort Reforms Are Turning the Tide

Workers’ Compensation for Contractors: How to Stay Compliant

How Proactive Communication Can Save Your Business from Insurance Pitfalls

Protecting Your Business from Employee-Related Claims

How Business Interruption Insurance Can Keep You Afloat During a Crisis

Unlocking the Best Rates: How Independent Agencies Offer More Personalized Insurance Options

Unveiling the Myths: What “Full Coverage” Auto Insurance Really Means for Drivers

Common Insurance Mistakes Small Business Owners Make (and How to Avoid Them)

Tell us about your health & lifestyle.

Drivers

Vehicles

Other Vehicles

Auto Claims/MVR Violations (within past 5 years)

Ownership Information

Mortgage Information

Monitoring System Information

Home Details

Valuable Personal Articles

Claims History

Insights that protect.
Knowledge that empowers.