Customer Name *FirstLastThank you for your interest in Archer Insurance. Who might you be? *I am the customerI am a realtor on behalf of a customerI am a Non-Realtor® professional How did you hear about Archer Insurance? *My RealtorMy Loan OfficerMy Car DealershipOther Professional ReferralFriends & FamilyJust around town...What Real Estate Office? *Keller WilliamsJ Barrett & CompanyCentury 21Lux RealtyChurchill PropertiesREMAXColdwell BankerOtherWhich state is the Keller Williams office in? *ConnecticutMaineMassachusettsNew HampshireRhode IslandVermontOtherWhich New Hampshire Keller Williams office?Bedford/MetropolitanConcordDoverKeeneLondonderryMeredithNashuaNorth ConwayPortsmouthSalemWolfboroWhich Connecticut Keller Williams office?DanburyFarmington/Farmington ValleyGlastonbury/East of the RiverHartford/Greater HartfordMansfield/Eastern ConecticutRidgefieldSimsburyStamfordStratford/SheltonTrumbullWallingford/Central CTOtherWhich Maine Keller Williams office?AuburnPortland/Greater PortlandWells/Keller Williams Coastal Realty - WellsYorkWhich Vermont Keller Williams office?BurlingtonWhich Massachusetts Keller Williams office? *AgawamAndoverBeverlyBoltonBraintree-QuincyBraintree/Showcase PropertiesCambridge-SomervilleCantonCenterville/Cape Cod-South CoastConcord/Boston NorthwestEastonFall River / South WatupaFalmouthFramingham / Boston MetroWestFranklin / KW Premier PropertiesLeominsterLexingtonLongmeadow / Pioneer ValleyNeedhamNewburyportNewton / Chestnut HillNorth AndoverNorth CentralNorthamptonNorwellNewton / Chestnut HillReading / Eastern MiddlesexRevere / Eastern MiddlesexSalemTopsfieldWestford / Merrimack ValleyWestminsterWestwoodWorcesterWhich Rhode Island KW Office?Bristol / East BayCranston / Central Rhode IslandLincoln / Leading Edge NRIMiddletown / Keller Williams Coastal Rhode IslandNorth KingstownProvidenceKeller Williams Agent's Name? *What is their name, and what office do they work out of? *Type the name of the KW office you are out of. *What real estate office are you with? *Describe your relationship to the customer. *Are you a loan officer, attorney, accountant, car dealership, or from some other industry? Your Name *FirstLastYour Phone # *Customer Phone *Your Email *Customer Email *Customer Address *Address Line 1Address Line 2CityPlease SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCurrently Insured? *YesNoWant to zip right to the end? YesNoBy uploading your current insurance declarations page(s) you can bypass the online portal. Do you have a copy of your declarations page to upload? *Yes - And I'll use that for an express quote.No - I'll just continue with this easy online form.If you have more than one attachment to upload, you can email them all to lou@insurewitharcher.com. Just reference your online quote request in the email. Thanks!Upload your declarations for express quoteYour declarations are those first few pages of the policy you receive each year from your current carrier. They often come in the mail, but are also easy to pull from your carrier's website. If you don't have access to these, it is as simple as calling your agent and asking them to email you a copy. Tell us about any changes you'd like us to make to the policy you've uploaded. (For instance; drivers, garaging address, coverage, vehicles, etc.)How many drivers? *1234Driver #1 *FirstLastDriver #1 license number *Driver #2 *FirstLastDriver #2 license number *Driver #3 *FirstLastDriver #3 license number *Driver #4 *FirstLastDriver #4 license number *Number of vehicles on policy *1234Does vehicle #1 have plates? *YesNoVehicle #1 plate numberDo you know the VIN# for vehicle #1?YesNoEnter vehicle #1 VINDoes vehicle #2 have plates? *YesNoVehicle #2 plate numberDo you know the VIN# for vehicle #2?YesNoEnter vehicle #2 VINDoes vehicle #3 have plates? *YesNoVehicle #3 plate numberDo you know the VIN# for vehicle #3?YesNoEnter vehicle #3 VINDoes vehicle #4 have plates? *YesNoVehicle #4 plate numberDo you know the VIN# for vehicle #4?YesNoEnter vehicle #4 VINVehicle #1 YearVehicle #2 YearVehicle #3 YearVehicle #4 YearVehicle #1 MakeVehicle #2 MakeVehicle #3 MakeVehicle #4 MakeVehicle #1 ModelVehicle #2 ModelVehicle #3 ModelVehicle #4 ModelPlease explain vehicle(s) uses in any form or business? Any student drivers with a 3.0+ GPA?YesNoAny student drivers live at school?YesNoPlace of EmploymentWe offer discounts to certain employersAre you an AAA member?YesNoEnter membership #Current living situation *OwnRentLive with familyOtherIf other, please explainChecking this box indicates that you have read this. *Archer Insurance is an independent insurance broker licensed by the Commonwealth of Massachusetts. Archer Insurance, Keller Williams Realty Beverly, Keller Williams Realty Eastern Middlesex and Keller Williams Realty Greater Newburyport are independent entities. Each are party to agreements pursuant to which commissions on insurance customer accounts are shared. These agreements do not increase or in any other way affect premiums should you elect to place your insurance coverage thru Archer Insurance.Sign here demonstrating that you understand the Archer/KW relationship.Clear SignatureWebsiteSubmit