HorsePower Pre-Quote Form | Centurion Insurance Group

HorsePower™ Pre-Quote Form

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Equine Quote Form

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Signature

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Date

General Information

Your Name*:

Email Address*:

Phone Number*:

Residence Address*:

City*:

State*:

Zip*:

Check if mailing address is different from residence address:

Residence Address:

City:

State:

Zip:

Date of Birth*:

Social Security # (last 4 digits)*:

Marital Status:

Single

Married / Civil Union

Spouse’s Name:

Date of Birth:

Social Security # (last 4 digits):

State of Residency:

May we email this quote to you?:

Yes

Horse/Animal Information

#	Horse Name	Age	Sex	Breed	Value	Use
1
2
3
4
5
6
7
8
9
10

Click to ADD another horse.

Your horses are boarded:

On site

Off site

I currently (check all that apply):

Board horses

Breed horses

Show horses

Train horses

Provide horses

Other, explain:

Gross annual earnings related to your equine pursuits (sales, winnings):

Number of Household Employees:

Est. Hours Worked per Year:

Number of Barn/Farm Employees:

Est. Hours Worked per Year:

Do you have other pets?

Yes

#	Do you show, breed or sell them?	Any history of bites or property damage?
1	Show Breed Sell	Yes No
Explanation of bites or property damage:
2	Show Breed Sell	Yes No
Explanation of bites or property damage:
3	Show Breed Sell	Yes No
Explanation of bites or property damage:
4	Show Breed Sell	Yes No
Explanation of bites or property damage:
5	Show Breed Sell	Yes No
Explanation of bites or property damage:
6	Show Breed Sell	Yes No
Explanation of bites or property damage:
7	Show Breed Sell	Yes No
Explanation of bites or property damage:
8	Show Breed Sell	Yes No
Explanation of bites or property damage:
9	Show Breed Sell	Yes No
Explanation of bites or property damage:
10	Show Breed Sell	Yes No
Explanation of bites or property damage:

Click to ADD another pet.

Home Insurance

Do you:

Own your home

Rent your home

Is it a condominium:

Yes

Current policies you have (home, auto, farm, etc.):

Year of Construction:

Miles to Fire Station:

Feet to Hydrant:

Years of system updates if home is older than 20 years:

Heating

Plumbing

Wiring

Roof

Check all that apply:

Fire Alarm

Sprinkler System

Burglar Alarm

Low Temperature Alarm

Local Smoke Detectors

Direct Report Smoke Detectors

Primary Heating Source (oil, propane, gas, wood, etc):

Supplemental-Heating Source (if any):

Do you have a pool:

Yes

Above Ground

In Ground

Is it fenced in:

Yes

Do you have a trampoline:

Yes

Home Insured Value:

Tack Value:

Detached structure(s) (barn, shed, garage, etc.) information:

#	Structure Type	Structure Value	Maximum number of hay bales stored at one time
1
2
3
4
5
6
7
8
9
10

Click to ADD another structure.

In what state are your vehicles registered:

Do you currently have auto insurance:

Yes

If so, with what carrier:

Policy expiration date:

Driver Information:

#	Name	Date of Birth	Sex	License # and State
1
2
3
4
5
6
7
8
9
10

Click to ADD another driver.

Vehicle Information:

#	Year	Make	Model	VIN	Use
1					Commute Pleasure Business
2					Commute Pleasure Business
3					Commute Pleasure Business
4					Commute Pleasure Business
5					Commute Pleasure Business
6					Commute Pleasure Business
7					Commute Pleasure Business
8					Commute Pleasure Business
9					Commute Pleasure Business
10					Commute Pleasure Business

Click to ADD another vehicle.

Trailer Information:

#	Year	Make	Model	VIN	Value
1
2
3
4
5
6
7
8
9
10

Click to ADD another trailer.

Other Vehicle/Equipment Information:

#	Year	Make	Model	VIN	Value
1
2
3
4
5
6
7
8
9
10

Click to ADD another vehicle/equipment.

Home or Auto Loss History (If Any)

#	Date	Type of Loss	Amount Paid Out
1
2
3
4
5
6
7
8
9
10

Click to ADD another loss.

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Personal Insurance

HorsePower™ Pre-Quote Form

Equine Quote Form