Lapolla Insurance Agency, llc.
Auto Health Home Life Business

Call us: (203) 292-5881

Fax: (866) 254-1323

Email: info@lapollainsurance.com

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Lapolla Insurance Agency, LLC.
425 Kings Hwy East
Fairfield, CT 06825

Phone: 203-292-5881
Fax: 866-254-1323

Email: info@lapollainsurance.com
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Quick contact

Quote

Auto Insurance Quote Request

* Mandatory fields

Automobile Information Sheet

* Applicants Name:
Applicants Address:
How long have to lived at address:
If <3 yrs previous address:
Do you own the home:
Current insurance compnay:
Current premium:
* Phone no.:
Prior Carrier:
Employer:
eMail:
Occupation:
College Degree:
Assoc. Batch.
Masters PhD.
SS#:
Policy #
Eff Date:

Vehicle Description
  Year Make/Model VIN
1.
2.
3.
4.

Vehicle Usage
  Miles Traveled Usage: Personal / Business or Work
1.
2.
3.
4.

Discounts Available
*Triple A:
- Member No.:
*Prepay:

Driver Info
Driver info 1
Name:
Driver Away?:
Sex :  
Mar/Stat:
DOB:
DL#:
State:
Where?:
Driver info 2
Name:  
Sex:: Driver Away?:
Mar/Stat:
DOB:
DL#:
State:
Where?:
Driver info 3
Name:    
Sex:: Driver Away?:
Mar/Stat:
DOB:
DL#:
State:
Where?:
Driver info 4
Name:  
Sex:: Driver Away?:
Mar/Stat:
DOB:
DL#:
State:
Where?:

Accidents/Convictions

 Check if None
Driver # Date of Acc/Conv Description Amt Paid($) Location

Coverages
Combined Single Limit: or
Split Limits: BI PD Limit
Med Pay:
Uninsured Motorist CSL: or Split Limit: BI
UM: Conversion or Standard?:
Comprehensive:
Veh 1 DED Veh 2 DED Veh 3 DED Veh 4 DED
 
Collision:
Veh 1 DED Veh 2 DED Veh 3 DED Veh 4 DED
 
Towing & Labor (Y/N)
Veh 1 Veh 2 Veh 3 Veh 4
 
Rental Reimbursement
Veh 1 Veh 2 Veh 3 Veh 4
 
No coverage of any kind is bound or implied by submitting information via this online form.
  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
 
By clicking "Get Quote" you agree to receive a phone call and/or email from Lapolla Insurance. We will not sell or distribute your information to any 3rd party.
 

Enter the security code you see above. Code is NOT case sensitive. *
 

* Mandatory fields

Motorcycle Information Sheet

* Full Name:
Street Address:
City, State & Zip:
* E-Mail Address:
Daytime Telephone:
Evening Telephone:
Fax:
Best Time To Reach You:    
# of years @ Current Address: Do You Own a Home?:
 

Current Insurance Information
Insurance Company Name:
(NOT Insurance Agency/Broker)		  
Policy Exp. Date: Premium Amt:
Term: How long with current?
 

Motorcycle Information
Motorcycle 1:
Year
Make/Model
Engine Size (cc)
Yearly Mileage
Usage
Type
Please describe any special equipment, you want insured, on this motorcycle. (List item and value in box to the right)
Motorcycle 2:
Year
Make/Model
Engine Size (cc)
Yearly Mileage
Usage
Type
Please describe any special equipment, you want insured, on this motorcycle. (List item and value in box to the right)
 

Coverage Information
Liability limits for bodily injury & property damage:
Uninsured Motorist Bodily Injury:
 

Deductibles
Comp. & Collision
Towing coverage
Rental Reimb.
Motorcycle 1:
Motorcycle 2:
 

Driver Information
Driver 1
* Gender:
Mail Female
* Name: Marital Status:
Date of birth: Driver's Education?:
Years Licensed: Defensive Driving:
Occupation: Good Student:
# Yrs Cycling Experience: SR 22 filing?:
 
Driver 2
* Gender:
Mail Female
* Name: Marital Status:
Date of birth: Driver's Education?:
Years Licensed: Defensive Driving:
Occupation: Good Student:
# Yrs Cycling Experience: SR 22 filing?:
 

Accidents / Violations in the last 5 years?
  Driver 1 Driver 2
Minor violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Chargeable Accident Cost($):
Major violations - drunk driving, reckless, hit and run, etc.
 

Any additional comments or information that might be helpful in your quote:
No coverage of any kind is bound or implied by submitting information via this online form.
  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
 
By clicking "Get Quote" you agree to receive a phone call and/or email from Lapolla Insurance. We will not sell or distribute your information to any 3rd party.
 

Enter the security code you see above. Code is NOT case sensitive. *
 

* Mandatory fields

Boat/Watercraft Quote

* Full Name:
Street Address:
City, State & Zip:
* E-Mail Address:
Daytime Telephone:
Evening Telephone:
Fax:
Best Time To Reach You:
 

Current Insurance Information
Insurance Company Name:
(NOT Insurance Agency/Broker)		  
Policy Exp. Date: Premium Amt:
Term: How long with current?
 

Vessel Description:
Year, Make, Model yr mk model
Length and Value $      
Horsepower
Maximum speed
Type of Hull
Body style
 

Power Description:
  Engine Year/Make/Model  
Engine 1
Engine Value, Type
  $  
  Engine Year/Make/Model  
Engine 2
Engine Value, Type
  $  
 

Trailer Description:
Trailer Year/Make/Model
 

Driver Information:
* Primary Driver Name
Age
Date of Birth
Years Boating experience
Any motor vehicle citations within the past 3 years?
Requested Limits of liability
Original Owner
Approved Safety Course completion
 

Any additional comments or information that might be helpful in your quote:

No coverage of any kind is bound or implied by submitting information via this online form
  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
 
By clicking "Get Quote" you agree to receive a phone call and/or email from Lapolla Insurance. We will not sell or distribute your information to any 3rd party.
 

Enter the security code you see above. Code is NOT case sensitive. *
 

* Mandatory fields

Applicant Information

Gender: Date of Birth:
Tobacco:    
Spouse: Date of Birth:
Children:    
Zip Code:    
 

Contact Information
* Name:
* Phone Number:
Email Address:
No coverage of any kind is bound or implied by submitting information via this online form.
  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
 
By clicking "Get Quote" you agree to receive a phone call and/or email from Lapolla Insurance. We will not sell or distribute your information to any 3rd party.
 

Enter the security code you see above. Code is NOT case sensitive. *
 

Home Insurance Quote Request

* Indicate year of update

* Mandatory fields

Homeowners Information Sheet
* Insure Name #1:
Address:
Employer:
Occupation:
SS#:
BDay:
* Phone:
Email:
Marital Status:
Year Built:
Eff Date:
No. of Families
No. of Stories
Square feet
# Bathrooms
# Fire places
* Insure Name #2:
Address:
Employer:
Occupation:
SS#:
BDay:
* Phone:
Email:
Marital Status:
 
Updates*
Wiring:
Plumbing:
Heating type:
Roofing:
 
Breakers Fuses
Tank
Basement
% Finished
Security
Fire Extinguisher:
Central Burglar:
Central Fire:
Smoke detector:
Hard Wired?:
 
Loss history
Any losses during the last three years? (Need date, type, description of loss):
 
Coverage/Limits of Liability
Dwelling: Deductible:
Personal Property: Flood Coverage?
Liability: Umbrella?
 
Scheduled items
Jewelry: Furs: Silverware:
Other: Amount: Quake:
 
Estimator Form on Reverse must be completed!!
Rating/underwriting info:
Prior Carrier: Policy #:
Any coverage declined, cancelled or non renewed? If yes, why?
 
OTHER LIABILITY EXPOSURES:
Unfenced swimming pool on premisetts:  
Trampoline?  
Watercraft, horses, dog?
If ye s, what kind?:
Wood/coal burning stove?
If yes, professionallyinstalled?
Waterfront Property?
If yes, distance from water:
Any other residence owned, occupied
or rented?
If yes, please provide
address andoccupancy
and coverages desired
Any animals
If yes what type?
Underground Oil Tank?
Purchase Price (If new purchase):
If new purchase, amount financed:
Completed by:
Date:
 

Residential Building Cost Guide Worksheet
1. No. of Stories:
1a. Construction:
1b. # of Families:
 
2. Total Square Footage of Dwelling:
3. Construction Planned?:
4. Garages
1 Car 2 Car 3 Car Detached
Attached Basement Built-In Car Port
5. Full Baths:
Half Baths:
6. Fireplace:
Chimneys:
8. Finished Basement Square Footage:
9. Central A/C:
Yes No
10. Porch/Breezeway:
Square Footage Open Closed
11. Balcony/Deck:
Square Footage        
12. Roof Material:
Asphalt Shingle Cedar Shake Slate Tile
13. Rooms:
Kitchen Dining Room
Living Room Family Room
Library Exercise Room
Bedrooms    
Other
14. Umbrella?
15. Atty Info:
No coverage of any kind is bound or implied by submitting information via this online form.
  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
 
By clicking "Get Quote" you agree to receive a phone call and/or email from Lapolla Insurance. We will not sell or distribute your information to any 3rd party.
 

Enter the security code you see above. Code is NOT case sensitive. *
 

* Mandatory fields

Applicant Information

* First Name:
* Phone
Credit Rating
* Last Name:
* Email
   
Birthdate
Type of rental property
Approximate year built (Example 1999)
How many years at this address?
How many years at previous address?
Property ZIP code
 

Property Information
Address  
City, State Zip
Approximate Square Feet    
Bedrooms
Fireplaces
Garage
Bathrooms
Stories
Security System
 

Policy Information:
Replacement value of all property $ (Example 15000)
Desired deductible (Most Common)
Desired liability coverage (Most Common)
Renters insurance claim in the past 5 years?
Yes No
Do you currently have renter's insurance?
Yes No
 
No coverage of any kind is bound or implied by submitting information via this online form.
  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
 
By clicking "Get Quote" you agree to receive a phone call and/or email from Lapolla Insurance. We will not sell or distribute your information to any 3rd party.
 

Enter the security code you see above. Code is NOT case sensitive. *
 

* Mandatory fields

Applicant Information

Full Name: Date of Birth:
Street Address:    
City, State & Zip:    
Coverage Amount:    
Type of Coverage:    
 

Contact Information
* Name:
* Phone Number:
Email Address:
No coverage of any kind is bound or implied by submitting information via this online form.
  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
 
By clicking "Get Quote" you agree to receive a phone call and/or email from Lapolla Insurance. We will not sell or distribute your information to any 3rd party.
 

Enter the security code you see above. Code is NOT case sensitive. *
 

Business Insurance Quote Request

* Mandatory fields

Personal information
* Name:
Address:
City:
ST:
Zip:
* Phone Business:
Cell:
Email:
DOB:
SS #:
Years of experience:
 
Business Information
* Name:
Years in bus:
Structure:
LLC C Corp
Corp Sole Prop
Address:
Website:
Tax ID:
Revenues:
Description of business:
Business property
(description/value):
Current Insurance Carrier:
Premium:
Renewal date:
Losses ( within 5years) describe:
Number of Employees:
Payroll :
Subcontractor costs:
 
No coverage of any kind is bound or implied by submitting information via this online form.
  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
 
By clicking "Get Quote" you agree to receive a phone call and/or email from Lapolla Insurance. We will not sell or distribute your information to any 3rd party.
 

Enter the security code you see above. Code is NOT case sensitive. *
 

* Mandatory fields

Business Name:
Premises Address:
City:
State:
Zip Code:
* Contact Name:
Phone #:
Ext #:
Fax:
Years in Business:
* Email Address:
Federal Employer's
ID #:
Description of Operations or SIC code:
 
Connecticut Commercial Vehicle Information
Vehicle   Year Make Model Body Type
1
2
3
4
5
 
What type of air bag system is each vehicle equipped with?
Vehicle
1  
2
3
4
5
 
What type of anti-lock brake system is each vehicle equipped with?
Vehicle
1
2
3
4
5
 
Does each vehicle have an alarm?
Vehicle
1
2
3
4
5
 
Connecticut Commercial Auto Insurance Coverage Information
Vehicle   Liability
Limits(x $1,000)		 Uninsured
Motorist(x $1,000)		 Medical Collision
Deductible		 Comprehensive
Deductible
1  
2  
3  
4  
5  
 
Driver Information
Driver   Drivers Name Date of Birth Gender Drivers License #
1  
2  
3  
4  
5  
 
Is each employee's driving record accident & violation free during the past 5 years?
Driver
1   If No, how many accidents? How many violations?
2   If No, how many accidents? How many violations?
3   If No, how many accidents? How many violations?
4   If No, how many accidents? How many violations?
5   If No, how many accidents? How many violations?
 
Was any employee's driver's license suspended during the past 5 years?
Driver
1  
2  
3  
4  
5  
 
Recent Insurance Information
Other Insurance
Company Used Within
Past 3 Years:
Losses past 3 years:
Description of losses
or loss runs:
Policy #:
Additional Information
or Comments:
 
No coverage of any kind is bound or implied by submitting information via this online form.
  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
 
By clicking "Get Quote" you agree to receive a phone call and/or email from Lapolla Insurance. We will not sell or distribute your information to any 3rd party.
 

Enter the security code you see above. Code is NOT case sensitive. *
 

* Mandatory fields

Business Name:
Premises Address:
City:
State:
Zip Code:
* Contact Name:
Phone #:
Ext #:
Fax:
Description of Operations or SIC code:
Years in Business:
* Email Address:
Current Insurance Company:
Policy Expiration Date:
Annual Sales:
$
Payroll:
$
Business Income:
$
Other Insurance Company Used Within Past 3 Years:
Policy #:
Losses past 3 years:
Description of losses or loss runs:
 
Coverage Amounts Desired:
Liability Limit Desired:
Deductible Desired:
Or choose other
liability limit amount:
$
Umbrella Amount Desired:
 
Connecticut Property Info:
Building 1
 
Building Value:
$
Contents Value:
$
Total Building Area:
Year Built:
Construction Type:
Sprinklers:
Central Alarm:
List Neighboring Businesses:
To the right: Distance
To the left: Distance
To the rear: Distance
 
Building 2
Building Value:
$
Contents Value:
$
Total Building Area:
Year Built:
Construction Type:
Sprinklers:
Central Alarm:
 
List Neighboring Businesses:
To the right: Distance
To the left: Distance
To the rear: Distance
 
Additional Information or Comments
 
No coverage of any kind is bound or implied by submitting information via this online form.
  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
 
By clicking "Get Quote" you agree to receive a phone call and/or email from Lapolla Insurance. We will not sell or distribute your information to any 3rd party.
 

Enter the security code you see above. Code is NOT case sensitive. *
 

* Mandatory fields

Business Name:
Premises Address:
City:
State:
Zip Code:
* Contact Name:
Phone #:
Ext #:
Fax:
Years in Business:
* Email Address:
Federal Employer's ID #:
Description of Operations or SIC code:
# of full-time employees:
# of part-time employees:
# of locations:
Estimated Annual Payroll:
$
Gross Sales:
$
 
Select all that apply to your Connecticut business:
Operate or lease aircraft/watercraft
Work above 15 feet
Use Subcontractors
Pre-employment physicals
Store, treat, dispose, or transport hazardour waste
Other
Work Underground
Require out of state travel
Delivery Service
Offer safety incentive programs
Work on vessels, docks, or bridges over water
 
Current Insurance Company:
Policy #:
Expiration Date:
 
 
What types of coverages do you currently have:
Benefit Liability Business Liability
Commercial Umbrella Directors & Officers Liability
Discrimination Errors & Omissions
Product Liability Professional Liability
Other    
 
Other Insurance Company Used Within Past 3 Years:
Policy #:
Losses past 3 years:
Description of losses or loss runs:
General Aggregate Limit (other than products completed):
Products/Completed Operations Aggregate Limit:
Umbrella Amount:
 
Building 1
Building Value:
$
Contents Value:
$
Total Building Area:
Year Built:
Construction Type:
Sprinklers:
Central Alarm:
 
List Neighboring Businesses:
To the right: Distance
To the left: Distance
To the rear: Distance
 
Building 2
Building Value:
$
Contents Value:
$
Total Building Area:
Year Built:
Construction Type:
Sprinklers:
Central Alarm:
 
List Neighboring Businesses:
To the right: Distance
To the left: Distance
To the rear: Distance
Additional Information or Comments:
 
No coverage of any kind is bound or implied by submitting information via this online form.
  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
 
By clicking "Get Quote" you agree to receive a phone call and/or email from Lapolla Insurance. We will not sell or distribute your information to any 3rd party.
 

Enter the security code you see above. Code is NOT case sensitive. *
 

© 2011 Lapolla Insurance Agency, LLC. All Rights Reserved.