Name: The RUOK Insurance Agency
Price range: $$

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Step 1 of 19

Name

This field is for validation purposes and should be left unchanged.

Types of Insurance*

Bundle Home and Auto

Home

Auto

Life

Umbrella

Valuable Items

Motorcycle

Boat

RV Trailer or Camper

Golf Cart

Renters

Date Policies Should Start

How did you hear about us?

Name of family/friend who told you

First Last

Your Agent

Primary Applicant

Primary Insured Name*

First Middle Last Suffix

Email*

Phone*

SMS Consent

By checking this box, you consent to receive text messages from The RUOK Insurance Agency at the mobile number provided regarding your insurance inquiries, quotes, and policy updates and promotional/marketing messages. Consent is not a condition of purchase. Message and data rates may apply. Message frequency varies. Reply HELP for help or STOP to cancel. View our Privacy Policy and Terms of Service

Date of Birth*

Month

Day

Year

Gender*

Drivers License Number*

Drivers License State*

Motorcycle Endorsement?

Yes

Attended an Approved Motorcycle Safety Course?

Yes

Years Riding Experience*

How often do you ride in season?*

Marital Status

Education Level

Occupation

Spouse Full Name*

First Middle Last Suffix

Spouse Date of Birth*

Month

Day

Year

Is there a Co-Applicant?

Yes

Co-Applicant

Co-Insured Name*

First Middle Last Suffix

Co-Insured Date of Birth*

Month

Day

Year

Co-Insured Gender*

Co-Insured Email

Co-Insured Phone

Co-Insured Drivers License Number

Co-Insured Drivers License State

Co-Insured Motorcycle Endorsement?

Yes

Co-Insured Education Level

Co-Insured Occupation

Bundle Your Policies

Bundling your insurance policies home/renters, auto, and umbrella as a package can save you money, and gives you more access to better carriers and better rates. Its a great way to maximize coverage and value.

Would you like to bundle your policies?

Yes, bundle my Homeowners, Auto, Umbrella

Yes, bundle my Renters and Auto

No thanks

Property Address

Property Address*

Street Address Address Line 2 City State ZIP Code

Property Map

Mailing Address*

Same as Property Address

Street Address Address Line 2 City State ZIP Code

Have you lived at this address for about 24 months or more?*

Yes

Prior Address where you lived*

Street Address City State ZIP Code

Homeowners Information

Preferred home insurance deductible*

The insurance deductible is the amount of money you will pay in an insurance claim before the insurance coverage kicks in and the company starts paying you. When you have a deductible, you have to come up with the amount of money for your deductible before a claim gets paid in many circumstances.

If a claim were to occur, please indicate a deductible that you feel you and your family could afford.

$1,000

$2,500

$5,000

$10,000+

If your house suffered extensive damage due to a Hurricane, would you and your family be financially stable if your policy contract had a deductible of: *

$1,000

$2,500

5% of the property value (Often $20,000 or more)

Not sure

Type of Home*

Primary Use For Home*

How many weeks per year will the property be rented?

Is the property advertised for rent online?

Example: AirBnB, Zillow, etc

Yes

How long will the property be vacant at one time?

How many months per year do you reside at this property?

0-4 months

5-8 months

9-12 months

Is there a caretaker?

Yes

Do you require an annual lease?

Yes

How is the Mobile Home situated?*

Primary Occupancy*

Will the property be titled in a Trust or Corporation?*

Example: Trust, LLC, Corporation, Partnership, etc.

Yes

Name on Title of Property*

Was the home purchased through a short-sale or foreclosure?*

Yes

Is this a New Purchase?*

Yes

Purchase Date*

Purchase Price

Will there be a Mortgage?

Yes

Are there multiple dwellings on this property?

Yes

Do you currently have a homeowners insurance policy?

Yes

Name of current home insurance company

Would you like a quote on flood insurance as well?*

While your homeowners insurance may pay for water damage due to broken pipes, flood insurance pays for damages caused by the rising of a body of water that covers normally dry land. The average year over year flood claim is $43,000

Yes

Do you have a whole home generator

Yes

Renters Information

Do you currently have a renters insurance policy?

Yes

Name of current renters insurance company

Animals

Do you have dog(s)?

Yes

Breed(s) of Dog(s)

Include species and breed. (ex. a dog; chihuahua)

Any dogs have bite history?

Yes

Home Information

Is home newly built?

Yes

Name of the builder

Only answer this question if home is currently under construction or was very recently finished being built.

Year Built

Square Feet

# of Stories

# of Bedrooms

# of Full Baths

# of Partial Baths

Primary Heating Type

If oil or propane, where is the tank located?

Construction Type

Roof Type

Foundation Type

Basement Type

Value of Finished Basement

Garage Type

Garage Number of Vehicles

Security System

Has Fireplace?

Yes

Has Pool?

Yes

Pool Type

In Ground

Above Ground

Is Pool Fenced?

Yes

Does pool have a diving board?

Yes

Does pool have a slide?

Yes

Any trampoline?

Yes

Is the trampoline netted?

Yes

Has there been any updates to the Roof, Plumbing, Heating, or Electrical?*

Yes

Roof Update Year*

Roof Update Level

Plumbing Update Year*

Plumbing Update Level

Heating Update Year*

Heating Update Level

Electrical Update Year*

Electrical Update Level

Solar Panels?*

Yes

Number of Solar Panels*

Value of Solar Panels*

Solar Panels are*

Leased

Owned

Were solar panels installed with a cutoff for emergency services?*

Yes

Unsure

Will the roof have to be replaced before the life expectancy of the solar panels?*

Yes

Unsure

Does home have any detached structures?*

Yes

What types of detached structures?*

Guest House

Pool House

Shed

Workshop

Deck

Other

Other type of detached structure

Are there currently any type of renovations or construction occurring on the property?*

Yes

Please detail the renovations or construction occurring.

Is there any existing damage or debris on the property?*

Yes

Any centrally monitored burglar or fire alarm systems?

Discounts available! Please note monitored alarms can be ONLY burglary, ONLY fire, or BOTH. Local can simply be smoke detectors or un-monitored alarm.

Yes, central station monitored BURGLAR alarm system

Yes, central station monitored FIRE alarm system

Community access discount?

Single Entry

Keycode Entry Gated

Gated with Guards

None

Photos of Home (Optional)

If you would like to attach any pictures of your home inside and/or outside, please do so here.

Drop files here or

Max. file size: 3 MB, Max. files: 6.

Valuable Items

Most home insurance policies allow you to schedule valuable items to your policy such as jewelry, fine art, firearms, antiques, bikes, cameras, certain electronics, collectibles, musical instruments, silverware, etc. If you would like to include any of these items, please do so below. If an item is ineligible for scheduling to your policy we will let you know.

Do you have any items you would like to schedule to your homeowners policy?*

Yes

Let's Discuss

List of Scheduled Items

Item Description

Item Value ($)

Do you have an appraisal?

Additional Drivers

Are there additional drivers in your household?*

Yes

Additional Driver 1

1. Driver Name*

First Middle Last Suffix

1. Driver Date of Birth*

1. Gender*

1. Relationship to Insured

1. Driver License #

1. Drivers License State

1. Is This Driver a Good Student (GPA 3.0 or above)?*

Yes

1. Is This driver an Away Student, 100+ miles from home?*

Yes

1. Is This Driver Retired?*

Yes

1. Is Driver active or retired veteran of military, police, fireman, EMT, paramedic, or other first responder?*

Yes

Add 2nd Driver

Add Another Driver

Additional Driver 2

2. Driver Name*

First Middle Last Suffix

2. Driver Date of Birth*

2. Gender*

2. Relationship to Insured

2. Driver License #

2. Drivers License State

2. Is This Driver a Good Student (GPA 3.0 or above)?*

Yes

2. Is This driver an Away Student, 100+ miles from home?*

Yes

2. Is This Driver Retired?*

Yes

2. Is Driver active or retired veteran of military, police, fireman, EMT, paramedic, or other first responder?*

Yes

Add 3rd Driver

Add Another Driver

Additional Driver 3

3. Driver Name*

First Middle Last Suffix

3. Driver Date of Birth*

3. Gender*

3. Relationship to Insured

3. Driver License #

3. Drivers License State

3. Is This Driver a Good Student (GPA 3.0 or above)?*

Yes

3. Is This driver an Away Student, 100+ miles from home?*

Yes

3. Is This Driver Retired?*

Yes

3. Is Driver active or retired veteran of military, police, fireman, EMT, paramedic, or other first responder?*

Yes

Add 4th Driver

Add Another Driver

Additional Driver 4

4. Driver Name*

First Middle Last Suffix

4. Driver Date of Birth*

4. Gender*

4. Relationship to Insured

4. Driver License #

4. Drivers License State

4. Is This Driver a Good Student (GPA 3.0 or above)?*

Yes

4. Is This driver an Away Student, 100+ miles from home?*

Yes

4. Is This Driver Retired?*

Yes

4. Is Driver active or retired veteran of military, police, fireman, EMT, paramedic, or other first responder?*

Yes

Add 5th Driver

Add Another Driver

Additional Driver 5

5. Driver Name*

First Middle Last Suffix

5. Driver Date of Birth*

5. Gender*

5. Relationship to Insured

5. Driver License #

5. Drivers License State

5. Is This Driver a Good Student (GPA 3.0 or above)?*

Yes

5. Is This driver an Away Student, 100+ miles from home?*

Yes

5. Is This Driver Retired?*

Yes

5. Is Driver active or retired veteran of military, police, fireman, EMT, paramedic, or other first responder?*

Yes

Add 6th Driver

Add Another Driver

Additional Driver 6

6. Driver Name*

First Middle Last Suffix

6. Driver Date of Birth*

6. Gender*

6. Relationship to Insured

6. Driver License #

6. Drivers License State

6. Is This Driver a Good Student (GPA 3.0 or above)?*

Yes

6. Is This driver an Away Student, 100+ miles from home?*

Yes

6. Is This Driver Retired?*

Yes

6. Is Driver active or retired veteran of military, police, fireman, EMT, paramedic, or other first responder?*

Yes

Vehicle 1

1. VIN*

1. Year*

1. Make*

1. Model*

1. Estimated Annual Miles*

1. Primary Use

1. Ownership*

Owned

Leased

1. Vehicle Financed*

Yes

1. Preferred COMPREHENSIVE Deductible*

1. Preferred COLLISION Deductible*

1. Name of Primary Driver

How long have you owned the vehicle?

Approximate months

1. Towing?*

Yes

1. Rental Car?*

Yes

Add 2nd Vehicle

Add a Vehicle

Vehicle 2

2. VIN*

2. Year*

2. Make*

2. Model*

2. Estimated Annual Miles*

2. Primary Use

2. Ownership*

Owned

Leased

2. Vehicle Financed*

Yes

2. COMPREHENSIVE Deductible*

2. COLLISION Deductible*

2. Name of Primary Driver

How long have you owned the vehicle?

Approximate months

2. Towing?*

Yes

2. Rental Car?*

Yes

Add 3rd Vehicle

Add a Vehicle

Vehicle 3

3. VIN*

3. Year*

3. Make*

3. Model*

3. Estimated Annual Miles*

3. Primary Use

3. Ownership*

Owned

Leased

3. Vehicle Financed*

Yes

3. COMPREHENSIVE Deductible*

3. COLLISION Deductible*

3. Name of Primary Driver

How long have you owned the vehicle?

Approximate months

3. Towing?*

Yes

3. Rental Car?*

Yes

Add 4th Vehicle

Add a Vehicle

Vehicle 4

4. VIN*

4. Year*

4. Make*

4. Model*

4. Estimated Annual Miles*

4. Primary Use

4. Ownership*

Owned

Leased

4. Vehicle Financed*

Yes

4. COMPREHENSIVE Deductible*

4. COLLISION Deductible*

4. Name of Primary Driver

How long have you owned the vehicle?

Approximate months

4. Towing?*

Yes

4. Rental Car?*

Yes

Add 5th Vehicle

Add a Vehicle

Vehicle 5

5. VIN*

5. Year*

5. Make*

5. Model*

5. Estimated Annual Miles*

5. Primary Use

5. Ownership*

Owned

Leased

5. Vehicle Financed*

Yes

5. COMPREHENSIVE Deductible*

5. COLLISION Deductible*

5. Name of Primary Driver

How long have you owned the vehicle?

Approximate months

5. Towing?*

Yes

5. Rental Car?*

Yes

Add 6th Vehicle

Add a Vehicle

Vehicle 6

6. VIN*

6. Year*

6. Make*

6. Model*

6. Annual Miles Driven*

6. Primary Use

6. Ownership*

Owned

Leased

6. Vehicle Financed*

Yes

6. COMPREHENSIVE Deductible*

6. COLLISION Deductible*

6. Name of Primary Driver

How long have you owned the vehicle?

Approximate months

6. Towing?*

Yes

6. Rental Car?*

Yes

Add 7th Vehicle

Add a Vehicle

Vehicle 7

7. VIN*

7. Year*

7. Make*

7. Model*

7. Annual Miles Driven*

7. Primary Use

7. Ownership*

Owned

Leased

7. Vehicle Financed*

Yes

7. COMPREHENSIVE Deductible*

7. COLLISION Deductible*

7. Name of Primary Driver

How long have you owned the vehicle?

Approximate months

7. Towing?*

Yes

7. Rental Car?*

Yes

Add 8th Vehicle

Add a Vehicle

Vehicle 8

8. VIN*

8. Year*

8. Make*

8. Model*

8. Annual Miles Driven*

8. Primary Use

8. Ownership*

Owned

Leased

8. Vehicle Financed*

Yes

8. COMPREHENSIVE Deductible*

8. COLLISION Deductible*

8. Name of Primary Driver

How long have you owned the vehicle?

Approximate months

8. Towing?*

Yes

8. Rental Car?*

Yes

Add 9th Vehicle

Add a Vehicle

Vehicle 9

9. VIN*

9. Year*

9. Make*

9. Model*

9. Annual Miles Driven*

9. Primary Use

9. Ownership*

Owned

Leased

9. Vehicle Financed*

Yes

9. COMPREHENSIVE Deductible*

9. COLLISION Deductible*

9. Name of Primary Driver

How long have you owned the vehicle?

Approximate months

9. Towing?*

Yes

9. Rental Car?*

Yes

Add 10th Vehicle

Add a Vehicle

Vehicle 10

10. VIN*

10. Year*

10. Make*

10. Model*

10. Annual Miles Driven*

10. Primary Use

10. Ownership*

Owned

Leased

10. Vehicle Financed*

Yes

10. COMPREHENSIVE Deductible*

10. COLLISION Deductible*

10. Name of Primary Driver

How long have you owned the vehicle?

Approximate months

10. Towing?*

Yes

10. Rental Car?*

Yes

Golf Cart(s) Information

Golf Cart (Serial Number)*

Golf Cart (Year)*

Golf Cart (Make)*

Golf Cart (Model)*

Preferred COMPREHENSIVE Deductible

Preferred COLLISION Deductible

Is golf cart financed?

Yes

Is golf cart registered for street use?

Yes

Where will the golf cart be stored?

Garage

Carport

Driveway

Other

Describe other storage location

Add 2nd Golf Cart

Add another Golf Cart

Golf Cart 2

Golf Cart 2 (Serial Number)*

Golf Cart 2 (Year)*

Golf Cart 2 (Make)*

Golf Cart 2 (Model)*

Preferred COMPREHENSIVE Deductible

Preferred COLLISION Deductible

Is golf cart financed?

Yes

Is golf cart registered for street use?

Yes

Where will the golf cart be stored?

Garage

Carport

Driveway

Other

Describe other storage location

Motorcycle Information

Motorcycle VIN*

Year*

Make*

Model*

CC Size*

Has the frame been modified to trike?*

Yes

Is this Modified frame, nitro oxide, turbo, or supercharger?*

Yes

Anti-lock Brakes?*

Yes

Anti-Theft*

None

Active Device

Recovery Device

Active & Recovery Device

Vehicle Purchase Year*

Annual Miles Ridden

Is this an off-road use vehicle?*

Yes

Off-Road Use*

Is there a Lien Holder or Additional Interest for the motorcycle?*

Yes, Lien Holder only

Yes, Additional Insured too

None

Lien Holder and/or Additional Interest*

Bank Name

Motorcycle Coverages

Preferred COMPREHENSIVE Deductible

Preferred COLLISION Deductible

Enhanced Injury Protection

Yes

Physical Damage

Actual Cash Value

None - Liability Only

Roadside Assistance

None

Roadside

Roadside w/ Trip Interruption

Carried Contents

None

$1,000

$2,000

$3,000

Accessories Coverage

Safety & Riding Apparel

Transport Trailer Coverage?

Yes

Trailer Value

Boat Information

Serial Number

Year*

Make*

Model*

Hull ID Number

Boat Registration Number

This is the ID number assigned to your boat by the state.

Hull Material

Number of Motors

Propulsion Type

Max Horsepower

Max Speed

Current Value

Fishing Equipment Coverage

Insure the Trailer?

Yes

RV, Trailer, or Camper Information

Year*

Make*

Model*

VIN

Length (in feet)*

Please enter a number greater than or equal to 2.

Year Purchased

Value (estimated ACV)

Garaging Zipcode

Number of days RV used per year

Original Owner?

Yes

Is there a lienholder?

Yes

RV Lienholder Name

Is RV parked at a single location year round?

Yes

Is RV rented commercially or used for business purposes?

Yes

Is RV rented out to others?

Yes

Is RV taken to/from work or used at a work location?

Yes

Primary Applicant Life Insurance

Amount of Coverage*

Duration*

Current Height (feet and inches)

Current Weight (lbs)

Nicotine User?*

Yes

Employer

Annual Salary

Household Income

Any known health issues?

Prescription Medications (name, dosage, frequency)

Have you been hospitalized in the last 5 years?

Yes

Family Members

Age of Parents & Siblings

Any known diseases

Age of Death (if deceased)

Cause of Death

Click the (+) icon to add additional family members.

Beneficiaries

Name

Date of Birth

Relationship to Applicant

Address

% of share

Click the (+) icon to add additional beneficiaries.

Does Co-Applicant need life insurance?*

Yes

Co-Applicant Life Insurance

Co-Applicant Amount of Coverage*

Duration*

Current Height (feet and inches)

Current Weight (lbs)

Nicotine User?*

Yes

Employer

Annual Salary

Any known health issues?

Prescription Medications (name, dosage, frequency)

Has co-applicant been hospitalized in the last 5 years?

Yes

Family Members

Age of Parents & Siblings

Any known diseases

Age of Death (if deceased)

Cause of Death

Click the (+) icon to add additional family members.

Beneficiaries

Name

Date of Birth

Relationship to Applicant

Address

% of share

Click the (+) icon to add additional beneficiaries.

Umbrella Coverage Information

Umbrella Liability Limit Requested

Number of Personal Properties*

Number of Rental Properties

Rural Vacant Land

450 acres maximum, development excluded

Urban Vacant Land

3 lots max, 3 acres per lot

Number of Vehicles*

Number of Drivers*

Number of Drivers (under age 25)

Number of Drivers (over age 75)

Number of Watercraft

Underwriting Questions: Auto, Motorcycle, Boat, RV, Golf Cart

Bodily Injury Liability Coverage Level?*

You hurt somebody coverage

Property Damage Liability*

You hit something coverage

Do you own the place you live in? (Discount Question!)*

Yes

Defensive Driver Course taken within the last 36 months? (Discount Question!)*

Yes

Are you willing to put a telematics computer on your vehicle(s) if it meant you could get a discount now or down the road?*

Yes

Any lapse in Auto insurance in the past year?

Yes

Not Applicable

Do you have any auto insurance currently?

Yes

Name of current auto insurance company

List all tickets, accidents, and moving violations you or any driver in your household had in the last 5 years

Underwriting Questions: Property, Homeowners, Renters, Condo, Landlords

Any lapse in Home insurance in the past year?*

Yes

Not Applicable

Has coverage on this property been cancelled, rejected, or non-renewed in the last three years?*

Yes

Not Applicable

Will the property be occupied within 30 days of the effective date?*

Yes

List all property related claims you have had in the last 5 years

Example: Water Damage on 5/10/2015, $30,000 Paid Out Claim is Closed.

Wrapping Up

Additional Comments

Attach Documents, Images, or Other Files

Drop files here or

Max. file size: 20 MB.

Would you like to create a user account?

Yes

Username*

Only letters and numbers.

Password*

Enter Password Confirm Password

Consent*

Like most insurance agencies, we use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.

I Agree

Auto Insurance Quote

Primary Applicant

Co-Applicant

Bundle Your Policies

Property Address

Homeowners Information

Renters Information

Animals

Home Information

Valuable Items

Additional Drivers

Additional Driver 1

Additional Driver 2

Additional Driver 3

Additional Driver 4

Additional Driver 5

Additional Driver 6

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

Vehicle 7

Vehicle 8

Vehicle 9

Vehicle 10

Golf Cart(s) Information

Golf Cart 2

Motorcycle Information

Motorcycle Coverages

Boat Information

RV, Trailer, or Camper Information

Primary Applicant Life Insurance

Co-Applicant Life Insurance

Umbrella Coverage Information

Underwriting Questions: Auto, Motorcycle, Boat, RV, Golf Cart

Underwriting Questions: Property, Homeowners, Renters, Condo, Landlords

Wrapping Up

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