How can we help you? "*" indicates required fields Step 1 of 26 - Quick Question First 3% Are you a current client of our agency?* Yes No What policy number(s) do you need help with if available? Add RemoveWhat is the nature of your inquiry?* General Question ID Card Request Policy Change Request Discuss A Claim Certificate of Insurance Other Describe your policy change requestWhat date do you need this policy change/request to take effect?* Which vehicle do you need an ID card for (please enter year, make, and model)?YearMakeModel Add RemoveYour Name* First Last Your Email* Your PhoneSMS Follow-up Consent Disclaimer: By checking this box and submitting this form, you consent to receive SMS messages from Leal Insurance Services, LLC at (210) 277-7544 about account notification, customer care or marketing. Message frequency may vary, and standard messaging and data rates may apply. Reply STOP to unsubscribe or HELP for assistance. For more details, see our Terms of Service and Privacy Policy and lealinsurance.comPlease list the Additional Insured and/or Certificate HolderAdditional Insured and/or Certificate Holder Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Details regarding your question, policy change, claim or other request:* Would you like a quote for personal insurance, or commercial/business insurance?* Personal Insurance — home, auto, renters, boat, umbrella, etc. Commercial / Business Insurance New here? Let's get you to the right questions. Welcome to Leal Insurance ServicesHelp us understand your situation so we can make the best use of your time — and ours.What brings you to Leal Insurance today?* I'm starting a new business and need coverage for the first time I want to compare prices on my existing coverage I want a better agent — mine isn't responsive or proactive I have a contract requirement needing specific coverage or limits Just browsing / not ready to switch yet No rush at all! We're here whenever you're ready. You can still continue this form — there's zero obligation and no spam. Or feel free to bookmark us and come back later. Timing & ReferralHelps us prioritize your file and reach out at the right pace for you.How soon are you looking to get coverage in place?* ASAP — my policy is expiring soon or I need coverage now Within the next 1–3 months My policy renews in 3–6 months Not applicable — I'm a new venture, ready to move forward How did you hear about Leal Insurance?*Select one...Referred by a friend or colleagueGoogle / online searchSocial media (Facebook, Instagram, LinkedIn)I've worked with you beforeChamber of Commerce / networking eventOtherWho referred you?Optional — only fill in if referred by someone. Your BusinessJust the basics to get started.Business Name*The name as it operates — this may appear on your policy.Year Business Started*New venture? Enter the current year.Type of Business* Contractor / Trades Professional Services Restaurant / Bar / Food Service Retail / Gym / Studio Property Owner / Landlord Auto Services Transportation / Trucking Other Select the option that best describes your primary business operations.Briefly describe what your business does*Coverage InterestsCheck everything that applies. Not sure? Check it anyway — we'll help you figure out what you need.Which coverages are you interested in?* General Liability (GL) Workers' Compensation Commercial Auto Commercial Property / BOP Professional Liability (E&O) Excess Liability / Umbrella I'm not sure — help me figure it out Select all that apply. We'll ask detailed questions for each one you select. How Would You Like to Proceed?We need a few more details to get started on your quotes. Choose what works best for you.📞Walk me through it with an advisor on a callOur team guides you through everything on a 20–30 min call. Just leave your contact info and we do the rest.💻Complete it myself online nowAnswer the detailed questions at your own pace. Takes 15–25 minutes. Organized by coverage type.How would you like to complete the remaining information?* Walk me through it with an advisor on a call Complete it myself online now Section 1 of 6 — Business DetailsLegal structure, address, and operations overview.Organization Type* Individual / Sole Proprietor Limited Liability Corp (LLC) Limited Liability Partnership (LLP) Corporation (Corp) Other Number of Owners / Partners* 1 Owner 2 Owners / Partners 3+ Owners / Partners Years of Industry Experience*Tax ID / EINEIN only — not your SSN. Required for Workers' Compensation quotes.Business WebsiteBusiness Physical Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your mailing address the same as your physical address?* Yes — same address No — different mailing address Mailing Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Describe your business operations in detail* Section 2 of 6 — Insurance BackgroundYour coverage history helps us find the best fit and avoid gaps.Have you worked with an insurance broker or agent before?* Yes No Does your business currently have any insurance coverage in place?* Yes No Name of Your Current Insurance CompanyCurrent Policy Expiration Date Current Annual Premium (Approximate)Will we be replacing this existing coverage?* Yes No Have you or your business had any claims or judgements filed against you in the last 5 years?* Yes No Please briefly describe the claim(s)Do you have any contract requirements for specific coverage limits, additional insured status, or special wording?* Yes No Describe your contract requirementsWhat is your target annual premium budget?Rough estimate is fine — helps us focus our carrier search.Do you agree to help us obtain your 5-year loss run report (claims history) from your prior insurer(s)?* Yes — I'll cooperate with the request No — I prefer not to This is standard for commercial insurance quotes. We handle the request — it usually requires just one signature from you. Section 3 of 6 — General LiabilityApplies to General Liability, Professional Liability (E&O), and Umbrella coverage.Estimated Annual Gross Revenue for the next 12 months*Your policy premium maybe based on this number so it's important we try to get this number as close to what you expect to make BEFORE taxes and expenses over the next 12 months.Estimated Annual Payroll*Include all W2 employees 1099 contractors that you DO NOT require to carry their own insurance. Do not include owner's salary/draws.Number of Employees (W2 and 1099)*Occupied Sq Ft*This is the occupied square footage for your business. If you have an office in your home, please list the size of the space for your home office.Contractor DetailsComplete this section for your contracting operations.Contractor Specialty*Select specialty...Remodeling / General ContractorCarpentryPaintingDrywallElectricalPlumbingHVACRoofingRemediation / RestorationLawn Care / LandscapingTree Trimming / ArboristPressure WashingWeldingOtherDo you have an active contractor's license?* Yes No License TypeLicense NumberCommercial Work %*Commercial + Residential should total 100%.Residential Work %*New Construction %*New Construction + Remodel/Repair should total 100%.Remodel / Repair %*How often do you use a written contract with customers?* Always Sometimes Never Do you subcontract any work?* Yes No Estimated Annual Cost of INSURED SubcontractorsEstimated Annual Cost of UNINSURED SubcontractorsAverage Cost Per Project*PLEASE NOTE: We are looking for the average total cost you charge a customer for a project you are working on.How many projects do you expect to complete in the next 12 months?*How many projects do you expect to complete in the next 12 months?Describe the work typically subcontractedYour subcontractor agreement requires: (check all that apply) Additional Insured status in favor of your business Waiver of Subrogation in your favor Primary & Non-Contributory wording Matching liability limits COI on file for minimum 3 years None of the above High-risk operations — check any that apply in the last 5 years or planned: Work near or in the oil & gas industry Structural welding Work on vehicle frames or heavy machinery Exterior work above 3 stories Underground or confined space work Demolition None of the above Do you offer any of the following services:* Outside surfacing cleaning (building siding, roofs, windows, etc) Cleaning or washing of aircraft or ship hulls Clean the interior of tanks Exterior work above 2 stories Cleaning solutions that are non-toxic and non-caustic Parking lots, driveways, sidewalks None of the above Do you offer any of the following services:* Hot Tar Application Torch Down Asphalt Shingle Installation Metal roofing Polyurethane foam None of the above Check all that applyMaximum PSI of the pressure apparatus used?*What precautions are taken to protect the public from potential injury on jobsite and the surrounding property from potential damage?*Do you do any structural welding work?*This could be any of the following, but not limited to: bridge construction, high rise buildings, metal buildings, stairs, catwalks, railings, etc. Yes No Restaurant / Food Service DetailsComplete this section for your food service operations.Do you or will you have an active liquor permit or license?* Yes No Estimated Annual Alcohol Gross Sales*Estimated Annual Non-Alcohol Gross Sales*Latest business closing time*Select an option...Midnight or earlierAfter midnight, by 2:00 AMAfter 2:00 AMOpen 24 hoursFood service compliance — check all that apply: Have a current, active health / food service permit Permit has never been suspended or revoked Never fined or cited for a critical health code violation Currently compliant with all local and state food establishment laws Keep records on stock rotation and cooler temperatures Do you have bouncers or security staff on premises?* Yes No Is your security personnel employed or contracted* Yes No Please check all that apply regarding your security:* Armed Guards or off-duty police officer Unarmed doormen/bouncers Bag checks, pat downs or frisking at the door Metal detector at the entrance to the premises Video surveillance through out the premises Responsible for ID checks Maintain Incident logs documenting when persons are refused service or other alcohol related events None of the above How many days are security footage tapes kept?*Auto Services DetailsComplete this section for your auto service operations.Which best describes your auto service business?*Select an option...Non-franchised auto dealershipAuto Paint & Body ShopAuto Mechanic (general — electrical, brakes, oil changes, etc.)Customization shopWash and/or DetailerOtherNumber of vehicles kept on your lot overnight*Average value of vehicles your business works on*Type of security surrounding the property: (check all that apply) Fully fenced-in lot Partially fenced-in lot Fully enclosed building No vehicles kept overnight Other Additional services offered: (check all that apply)* For-hire towing (no repo) Forced repo towing Loaner / rental vehicle arrangements Roadside service Mobile service (off-site repairs or detailing) Used tire sales / retreading None of the above Professional Liability (E&O) — Are you interested in a quote?* Yes — include a quote I have this coverage elsewhere and am not interested in a quote Not sure if I need it No — I understand the risk and decline this coverage Excess Liability / Umbrella — Are you interested in a quote?* Yes — include a quote Not sure if I need it No — I decline this coverage at this time Umbrella / Excess Liability limit being requested or required by contractEnter the dollar amount without commas. Section 4 of 6 — Workers' CompensationHelps us classify your employees correctly for accurate rates.Do you have any W2 employees (other than owners)?* Yes No Do you use any 1099 independent contractors?* Yes No Owner / Partner Coverage Selection* INCLUDE owners / partners in Workers' Compensation coverage EXCLUDE owners / partners from Workers' Compensation coverage Estimated Annual W2 Payroll*Estimated Annual 1099 Independent Contractor Costs*Describe the types of work your employees perform*Do any employees perform work outside of Texas?* Yes No Which other states do your employees work in?* Section 5 of 6 — Commercial AutoCovers your business vehicles and drivers.Does your business have a DOT# or MC# (or plan to get one in the next 6 months)?* Yes No DOT NumberMC Number (if applicable)Average Driving Radius for Your Business*Select an option...Local — 50 miles or lessIntermediate — more than 50, less than 200 milesIntrastate — more than 200, less than 500 milesInterstate — more than 500 milesAverage Number of Jobsites / Stops Visited Daily*Select an option...1–2 per day3–5 per day5+ per dayAuto Liability Limit Requested*Select an option...$100,000 CSL$300,000 CSL$500,000 CSL$1,000,000 CSL (agency recommended)Additional coverages needed: (check all that apply) Hired & Non-Owned Auto Motor Truck Cargo Physical Damage on owned vehicles Trailer Interchange Rental Reimbursement Are any business vehicles leased or rented on a long-term basis?* Yes No Interested in Telematics / GPS discount?* Yes No How would you like to provide your driver list?* Enter all drivers now I will email the driver list to Leal Insurance after submission Driver List*Example: Jane Doe | 01/15/1985 | TX12345678 | 4 years | EmployeeHow would you like to provide your vehicle list?* Enter all vehicles now I will email the vehicle list to Leal Insurance after submission Vehicle List*Example: 2021 | Ford | F-150 | 1FTFW1E53MKD12345 | Full CoverageAdditional coverage notes or requirements Section 6 of 6 — Commercial Property / BOPCovers your physical location, equipment, and inventory.What property coverage are you looking for? (check all that apply)* Building Coverage — I own the building Business Personal Property — equipment, inventory, furniture Both building and contents Is this for a purchase or new acquisition?* Yes No Estimated Closing Date Purchase PriceDo you own or lease this location?* I own the building I lease / rent the space Type of Property*Select an option...Office buildingRetail / storefrontWarehouse / industrialRestaurant / barShopping centerOtherYear the Building Was Built*Number of StoriesTotal Building Square Footage*Percentage of Building Occupied by You (Owner/Tenant)Percentage of Building Currently VacantIs there a sign on premises NOT attached to the building?* Yes No Estimated Replacement Cost of SignType of Alarm / Security System* None Local alarm only Centrally monitored — paid service (ADT, Vivint, SimplySafe, etc.) Video surveillance What percentage of the building is sprinklered?Mechanical updates in the last 20 years — check all that apply: Electrical updated Plumbing updated HVAC updated Roof updated None / building is under 20 years old Year of Last Electrical Update*Type of Electrical*Select...Circuit BreakersFuse BoxKnob & TubeUnknownYear of Last Plumbing Update*Type of Plumbing*Select...PVC / PEXCopperGalvanizedLeadUnknownYear of Last HVAC Update*Type of HVAC*Select...Central AC & Gas HeatingCentral AC & Electric HeatingWindow Unit — Cooling & HeatingWall Furnace OnlyOtherYear of Last Roofing Update*Type of Roofing*Select...Comp ShinglesFlat — Built-up SmoothFlat — Tar & GravelMetal RoofOther Almost Done — Contact InformationWe'll review your submission and reach out within 1 business day — often the same day.Owner's Name* First Last Owner's DOB* Best Phone Number*Best Email Address* Preferred Contact MethodNo preferenceCall meText meEmail meNo preference📅 Book Your Free ConsultationSkip the back-and-forth — pick a time that works for you right now:🗓 Pick a Date & Time That Works for YouOpens in a new tab · 20–30 min · No obligationUpload Your Current Coverage Documents (Optional) Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 10 MB, Max. files: 5. Share dec pages, certificates of insurance, or any current policy documents so we can analyze your existing coverage and identify gaps or savings opportunities.Anything else we should know?SMS / Text Message Consent SMS / Text Message ConsentI agree to receive text messages from Leal Insurance Services regarding my inquiry. Message & data rates may apply. Reply STOP to opt out at any time.Privacy Policy Agreement Privacy Policy AgreementBy submitting this form, I agree that my information will be used solely to prepare a coverage review and contact me about Leal Insurance Services. I understand that my data will never be sold to third parties. Let's make sure we're a great fitWhat's bringing you here today?* Purchasing a new home or investment property My renewal came in and rates went up Unhappy with my current agent's service I want to bundle my policies and save Moving into a new rental soon Just exploring / comparing options How soon do you need this handled?* Right away (closing date or expiring policy within 30 days) Within 1–3 months Sometime this year No specific timeline Where are you in the decision process?* I'm ready to switch if the price and service are right I'm collecting a few quotes to compare Just curious what's out there — no commitment How would you like to get your quotes? Talk with an Advisor Complete it Myself Let's get you scheduledWhat types of insurance do you need quoted? (check all that apply)* Home / Townhome Condo Renters Insurance Personal Auto Landlord / Investment Property Watercraft / Boat RV / Travel Trailer Motorcycle / ATV / UTV Personal Umbrella Your contact informationYour name* First Last Cell / Mobile Number*Email Address* Upload your current policy dec pages (optional but highly recommended)Sharing your current declarations pages lets us review your existing coverage for gaps, redundancies, and potential savings before the call — so we can make the most of your time together.Current policy declarations page(s) Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, Max. file size: 5 MB. Anything you'd like us to know before the call?SMS / Text Consent I agreeI consent to receive SMS/text messages from Leal Insurance Services for scheduling and follow-up purposes. Message & data rates may apply. Reply STOP to opt out.📅 Ready to pick your call time?After submitting this form, click below to choose a date and time that works for you.Open Scheduling Calendar → Tell us about yourselfYour full name* First Last Date of Birth* Current Occupation*Highest Level of Education Achieved*Please choose from the dropdown listHigh School / GEDSome College (no degree)Associate's DegreeTrade or Technical CertificateBachelor's DegreeGraduate / Professional DegreeContact & AddressCell / Mobile Number*Email Address* Current Mailing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code SMS / Text Consent I agreeI consent to receive SMS/text messages from Leal Insurance Services. Message & data rates may apply. Reply STOP to opt out.Marital StatusWhat is your current marital status?* Single Married Divorced Domestic Partnership Spouse / Partner Full Name* First Last Spouse / Partner Date of Birth* How did you hear about us?Please tell us how you learned about Leal Insurance Services:* Referred by a current LIS client Referred by a Mortgage Broker, Realtor, or Other Insurance Agent Google Search ChatGPT or other AI Search Social Media Networking Group (BNI, Chamber of Commerce, Marketing Event) Other Please tell us more: What are we quoting for you?What type of insurance quotes are you requesting? (check all that apply)* Home / Townhome Condo Renters Insurance Personal Auto Landlord / Investment Property Watercraft / Boat RV / Travel Trailer Motorcycle / ATV / UTV Personal Umbrella What's prompting the switch?What has you shopping for a new insurance program? (check all that apply)* Looking to bundle and save Purchasing a new residence or investment property Moving into a new rental Current premiums are too expensive Seeking better service and/or communication Any additional context you'd like us to know up front? Property InsuranceWhat type of property coverage are you looking for?*Single Family Home / Duplex / Triplex / QuadplexTownhomeCondoLandlord / Rental / Investment PropertyRenters InsuranceIs the mailing address the same as the property address?* Yes No Property Address:This should be the address for the location you are looking to insure. Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this a new purchase?* Yes No Is the property titled to a business entity, estate, or trust?* Yes No Expected closing / move-in date:* Name of business entity, estate, or trust:*Do you (or if buying, will you) have a mortgage on the property?*Select from the dropdown belowI do/will have a mortgage — premiums escrowedI do/will have a mortgage — premiums NOT escrowed (paid in full)I do/will have a mortgage — premiums NOT escrowed (paid monthly)I do not / will not have a mortgage on the propertyUse & OccupancyWhat is the intended use of this property?*Select from the dropdown belowFull-time primary residencePrimary residence — will rent out a portionSecondary / vacation home — no intent to rentSecondary / vacation home — will rent part-timeFull-time rental / investment propertyLeasing period:* Short-term / daily rentals (Airbnb, VRBO, etc.) Long-term (6-month minimum contracts required) Who manages your property?* I manage it myself I outsource management to a property manager Property manager name and address (for notification purposes):*Does your property manager require Additional Insured / Interest status on the policy?* Yes No Tenant screening requirements (check all that apply): Rental application with credit, background & eviction check Renters insurance required on file Regular inspection of the property Smokers prohibited on the lease Estimated personal property replacement value (contents in a total loss):*Basic Underwriting DetailsWhat year was the property built?*Approximate square footage of the property:*Do you have any animals on the property?* Yes No Please list all dog breeds, farm animals, or exotic animals:*Is there a pool on the property?* Yes No Does the pool have a slide?* Yes No Does the pool have a diving board?* Yes No Is there a self-latching gate surrounding the pool?* Yes No Is there a trampoline on the property?* Yes No Are there solar panels on the property?* Yes No Solar panel attachment:* Attached to the main dwelling Attached to another structure on property Free-standing Are the solar panels owned or leased?*OwnedLeasedTotal cost of the solar panels:*Where is your water heater located?*Please select an option from the dropdownIn the attic or on the second storyIn the garageIn an exterior closetIn an interior closet on the ground floorWhat kind of water heater do you have?*Tank water heaterTankless water heaterConstruction & Systems (Older Dwelling Questionnaire)Year of last major ROOF update:*Type of Roof:*Please select an option from the dropdownComposition ShinglesMetalClay / Concrete TileTar & GravelOtherYear of last major ELECTRICAL update:*Type of Electrical:*Please select an option from the dropdownCircuit BreakersFuse BoxKnob & TubeUnknownYear of last major PLUMBING update:*Type of Plumbing:*Please select an option from the dropdownPVC / PEXCopperGalvanizedLeadUnknownYear of last major HVAC update:*Type of HVAC:*Please select an option from the dropdownCentral AC & Gas HeatCentral AC & Electric HeatWindow Unit — Cooling & HeatWindow Unit — Cooling OnlyWall Furnace OnlyDiscounts & Safety FeaturesCheck all safety features that apply to your home: Smoke alarm Local burglar alarm Centrally monitored fire alarm (ADT, Vivint, SimpliSafe, etc.) Centrally monitored intrusion alarm (ADT, Vivint, SimpliSafe, etc.) Water leak sensor Current Insurance & Additional Coverage NeedsWho is your current insurance carrier?*How much are you currently paying (monthly or annual)?*Additional coverages to include in your quote: (optional) Schedule high-value items (jewelry, art, guns, collectibles) Flood (rising water from outside the dwelling) Wind Coverage (Texas coastal properties only) Collections (stamps, coins, precious metals, sports memorabilia) Service/Utility Line (buried utility lines on property) Upload elevation certificate, WPI-8, or current policy (if available): Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, Max. file size: 5 MB. Personal Auto InsuranceDo you currently have auto insurance?* Yes No Why don't you currently have auto insurance?*Name of your current auto insurance provider:*How much do you pay for your auto insurance (monthly or full term)?*Is your mailing address the same as where your vehicles are garaged overnight?* Yes No Garaging address for the vehicle(s):* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Driver DetailsDrivers — include yourself, spouse/partner, and all licensed household members*Full NameDate of BirthTX Driver's License # Add RemoveVehicle DetailsVehicle Information*Year / Make / ModelVINLiability ONLY or "Full Coverage"Years OwnedPrimary Use (Pleasure / Commute)Lienholder Add RemoveCoverage PreferencesLiability Limits:*Please select an option from the dropdown list30/60/25 (Texas state minimums)50/100/50100/300/100 ← Agency recommended250/500/100 (usually required for umbrella)500/500/100Additional coverages to include in your auto quote:* Uninsured/Under-insured Motorist Coverage (UM/UIM) Personal Injury Protection (PIP) Roadside Assistance Rental Car Coverage (requires at least Comprehensive) Original Equipment Manufacturer (OEM) Parts Coverage Are you interested in a Telematics Discount (drive-tracking app)?* Yes — I'm a safe driver! No thanks Business or Commercial UseAre any household vehicles used for any of the following?* Transporting goods, materials, or people (other than rideshare) Vehicle has business branding, logos, or wraps Vehicle titled in a business entity's name Uber / Lyft / DoorDash / Amazon Delivery Other business use (client visits, jobsite to jobsite, etc.) None of the above Upload current auto declarations page (if available):Accepted file types: pdf, jpg, jpeg, png, Max. file size: 5 MB. Watercraft / Boat InsuranceHave you had boat/watercraft insurance in the last 12 months without a lapse?* Yes No Who is your current insurance carrier?*How much are you currently paying for boat/watercraft insurance?*Is the mailing address where you keep your boat when not in the water?* Yes No Address where your boat is kept overnight:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Boat / Watercraft DetailsWatercraft / Boat Information*Year / Make / ModelHull ID (HIN)Hull Length (ft)Inboard / Outboard Add RemoveMaximum horsepower of the engine(s):*Operator InformationBoat / Watercraft Operators*Full NameDate of BirthTX Driver's License #Years of Boating Experience Add RemoveCoverage PreferencesLiability Limits:*Please select an option from the dropdown list30/60/2550/100/50100/300/100 ← Agency recommended250/500/100Additional coverages to include:* Uninsured/Under-insured Motorist Coverage (UM) Personal Injury Protection (PIP) Tow Assistance Personal Property Coverage None of the above Amount of Personal Property Coverage: RV / Travel Trailer InsuranceHave you had RV/Travel Trailer insurance in the last 12 months without a lapse?* Yes No Who is your current RV / Travel Trailer insurance carrier?*How much are you currently paying for RV / Travel Trailer insurance?*Is your mailing address the same as where you garage your RV/Travel Trailer overnight?* Yes No Garaging address for your RV / Travel Trailer:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code RV / Travel Trailer DetailsRV / Travel Trailer Information*Year / Make / ModelVINLength (ft)Type (Bumper Pull, 5th Wheel, Class A/B/C Motorhome) Add RemoveHow is the vehicle used?* Recreationally Part-time residence (parked at RV park) Full-time residence Business use / rented to others Driver InformationAre the drivers the same as the drivers on your auto policy?* Yes No Driver List*Full NameDate of BirthTX Driver's License # Add RemoveLiability Limits:*Please select an option from the dropdown list30/60/25 (Texas state minimums)50/100/50100/300/100 ← Agency recommended250/500/100500/500/100Additional coverages to include:* Uninsured/Under-insured Motorist Coverage (UM/UIM) Personal Injury Protection (PIP) Tow Assistance Personal Property Coverage None of the above Amount of Personal Property Coverage:Upload a copy of your current RV/Travel Trailer policy (if available):Accepted file types: pdf, jpg, jpeg, png, Max. file size: 5 MB. Motorcycle / ATV / UTV / Golf Cart InsuranceHave you had Motorcycle/ATV/UTV/Golf cart insurance in the last 12 months without a lapse?* Yes No Have you had any claims on these policies in the last 5 years?* Yes No Who is your current insurance provider?*How much do you pay for this coverage?*Is your mailing address the same as where you garage your Motorcycle/ATV/UTV/Golf cart overnight?* Yes No Garage address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Driver DetailsAre the drivers the same as the drivers on your auto policy?* Yes No Drivers Information*Full NameDate of BirthTX Driver's License #Motorcycle Endorsement (Y/N)MC Safety Course in last 3 years (Y/N) Add RemoveVehicle DetailsVehicle Information*Year / Make / ModelVINLiability ONLY or "Full Coverage" Add RemoveHow often are the vehicles used?*Do any of the following apply?* Any vehicle has performance enhancements Used for competitive purposes Off-roading use only Business use None of the above Upload a copy of your current Motorcycle/ATV/UTV policy (if available):Accepted file types: pdf, jpg, jpeg, png, Max. file size: 5 MB. Personal Umbrella / Excess LiabilityDo you currently have an umbrella policy in place?* Yes No Who is your current umbrella policy provider?*What is your current limit of liability?*What is your desired coverage limit?*Please select an option from the dropdown list$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000Umbrella Underwriting QuestionsOwned Property Information*# of SFD / Duplexes# of Triplexes# of Quadplexes Add RemoveVehicle Information*# of Autos# of Motorcycles / ATV / UTV / Mopeds# of RV / Travel Trailers Add RemoveNumber of boats / watercraft you own:*Maximum horsepower of any watercraft you own:*Driver Information*# of drivers under age 22# of drivers age 22 and overAny household members excluded from underlying policy? (Y/N) Add RemoveDriving History — all covered drivers combinedDriving History*# of at-fault accidents in the last 3 years# of minor moving violations in the last 3 years# of MAJOR violations in the last 3 years (DUI, reckless driving, etc.) Add RemoveUpload current umbrella declarations page (if available):Accepted file types: pdf, jpg, jpeg, png, Max. file size: 5 MB. Setting ExpectationsIf we present a competitive option, how quickly are you looking to move forward?* Immediately — I'm ready to bind coverage Within the next 30 days 30–90 days Just gathering info — no rush Have you ever worked with an independent insurance broker before?* Yes No Any other concerns, issues, or thoughts before we move forward?Authorization and Consent* I agreeI authorize Leal Insurance Services to use the information provided in this form to shop and present insurance quotes on my behalf. I understand that submitting this form does not bind coverage and does not constitute a policy. I confirm that the information I have provided is accurate to the best of my knowledge.
