Request a Quote November 18, 2013by picadesign We want to make it as easy as possible for you to get a fast, accurate insurance quote. Let's talk: The most accurate insurance quotes require a personal conversation. When possible, we’ll be in touch the same business day for forms submitted Monday through Friday from 9 a.m. to 3 p.m. and the next business day for forms submitted during the evening or on the weekend. Please remember that insurance coverage cannot be bound or changed via this website form. We must talk with you in person. Please complete the form below.What type of insurance are you looking for? * RequiredHomeCarFloodBusinessMarineEmployee Benefits/Heath InsuranceMedicareTravel or TripOtherHome Insurance There is no substitute for a personal conversation. This form will help us start a home insurance quote for you. When possible, we’ll be in touch the same business day for forms submitted Monday through Friday from 9 a.m. to 3 p.m. and the next business day for forms submitted during the evening or on the weekend. Please remember that insurance coverage cannot be bound or changed via this website form. We must talk with you in person.Car Insurance There is no substitute for a personal conversation. This form will help us start a car insurance quote for you. Whenever possible, we’ll be in touch the same business day for forms submitted Monday through Friday from 9 a.m. to 3 p.m. and the next business day for forms submitted during the evening or on the weekend. Please remember that insurance coverage cannot be bound or changed via this website form. We must talk with you in person.Flood Insurance There is no substitute for a personal conversation. This form will help us start a flood insurance quote for you. Whenever possible, we’ll be in touch the same business day for forms submitted Monday through Friday from 9 a.m. to 3 p.m. and the next business day for forms submitted during the evening or on the weekend. Please remember that insurance coverage cannot be bound or changed via this website form. We must talk with you in person.Business Insurance There is no substitute for a personal conversation. This form will help us start a business insurance quote for you. Whenever possible, we’ll be in touch the same business day for forms submitted Monday through Friday from 9 a.m. to 3 p.m. and the next business day for forms submitted during the evening or on the weekend. Please remember that insurance coverage cannot be bound or changed via this website form. We must talk with you in person.Marine Insurance There is no substitute for a personal conversation. This form will help us start a marine insurance quote for you. When possible, we’ll be in touch the same business day for forms submitted Monday through Friday from 9 a.m. to 3 p.m. and the next business day for forms submitted during the evening or on the weekend. Please remember that insurance coverage cannot be bound or changed via this website form. We must talk with you in person.Benefits/Health Insurance There is no substitute for a personal conversation. This form will help us start a benefits/health insurance quote for you. Please note that the open enrollment period for individual health insurance under the Affordable Care Act for 2019 closed on Dec. 15, 2018. Until the next open enrollment period, you can enroll only under a special exception, for which we refer you to healthcare.govThis form will help us start a travel or trip insurance quote for you. But we will need to speak with you directly. Whenever possible, we’ll be in touch the same business day for forms submitted Monday through Friday from 9 a.m. to 3 p.m. and the next business day for forms submitted during the evening or on the weekend. Please remember that insurance coverage cannot be bound or changed via this website form. We must talk with you in person. IMPORTANT NOTICE: On Jan. 23, 2020, the U.S. State Department issued a travel warning not to travel to China due to the Coronavirus. The World Health Organization declared the Coronavirus a Global Health Warning on Jan. 30, 2020. As a result, the Coronavirus is no longer an unforeseen event for travel to China starting on Jan. 24, 2020, and for travel worldwide starting on Jan. 31, 2020. To activate cancellation benefits under a trip insurance policy, a CDC travel warning is not a covered incident. Even if a policy is purchased prior to the date above, trip cancellation or trip interruption coverage related to Coronavirus would not be covered unless an individual had purchased the cancel for any reason upgrade. Cancel for any reason coverage is still available if you purchase a trip insurance policy within 20 days of making your initial trip deposit. If you are eligible for this coverage, you must specifically request it and list the date of your initial trip deposit.This form will help us start a travel or trip insurance quote for you. But we will need to speak with you directly. Whenever possible, we’ll be in touch the same business day for forms submitted Monday through Friday from 8 a.m. to 4:30 p.m. and the next business day for forms submitted during the evening or on the weekend. Please remember that insurance coverage cannot be bound or changed via this website form. We must talk with you in person. IMPORTANT NOTICE: The World Health Organization declared the Coronavirus a Global Health Warning on Jan. 30, 2020. As a result, the Coronavirus is no longer an unforeseen event for travel to China starting on Jan. 24, 2020, and for travel worldwide starting on Jan. 31, 2020. To activate cancellation benefits under a trip insurance policy, a CDC travel warning is not a covered incident. Even if a policy is purchased prior to the date above, trip cancellation or trip interruption coverage related to Coronavirus would not be covered unless an individual had purchased the cancel for any reason upgrade. Cancel for any reason coverage is still available if you purchase a trip insurance policy within 10 days of making your initial trip deposit. If you are eligible for this coverage, you must specifically request it and list the date of your initial trip deposit.Medicare Fact Finder There is no substitute for a personal conversation. This form will help us find a Medicare plan that’s right for you. You will notice this form does not ask for any personal information (date of birth, doctor’s names, prescription types, etc.). This is by design. Security of your personal information is very important to us. We can discuss this more when we meet or talk by phone.Name * Required First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email * Required For travel/trip insurance, we will contact you by email.Phone (###) ###-####Preferred method of contact * RequiredEmailPhonePreferred method of contact * RequiredEmailPhone (Please call me about my health care coverage options.)Where is the home located? Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Please tell us what type of insurance coverage you are interested in.Do you have Part A and B Coverage? If so, what is the effective date?What type of health coverage do you have now?An individual planCoverage as part of a spouse or partner's planDo you travel often and need coverage that travels with you?YesNoPlease tell us what you want most in a Medicare plan.Overall costI don't mind copays if my monthly premium is lowerI would consider switching to a doctor in a plan's networkI'm comfortable getting a referral to see a specialistI would go to a retail chain to fill my prescriptionsI would prefer to use a mail order pharmacyI could use help managing chronic, recurring medical conditions or health issuesHaving dental and vision coverage is important to meAre you interested in discussing any specific Medicare plans or carriers?(This is a solicitation for insurance.)YesNoSo we can serve you more effectively and efficiently, please tell us which of our locations is most convenient for you.RocklandCamdenBelfastSouthwest Harbor (L.S. Robinson Co.)No preferenceAges today of all who are traveling with you(separate by comma)Date of departure - must be mm/dd/yyyy format(must be within 15 months of today to get a quote) Date Format: MM slash DD slash YYYY Date of return (mm/dd/yy) - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY Non-refundable cost of your trip? * RequiredDate of initial non-refundable deposit? * RequiredYour state of residenceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificYour ZIP codeAre you a current customer of Allen Insurance and Financial? * RequiredYesNoPlease tell us the type of insurance you are interested in.(check box all that apply) Group Health for Business Short-Term Medical Life or Disability Other You selected "other" above, please describe:What type of insurance you are interested in? Boat/Yacht Marina/Boatyard Commercial Vessel Operations Crew Health Insurance Yacht Club Other You selected "other" above, please describe:Business NameIn what state is your business located? * RequiredType of businessContractorRetailerProfessional ServicesNon-ProfitPlease tell us the type of business insurance coverage you are interested in.Commercial PackageCommercial PropertyCommercial AutoWorkers CompensationBondLiability InsuranceCyber RiskIs this property:Your primary residenceA vacation home/secondary residenceAre you:The owner of this propertyA prospective buyer of this propertyAn agent of the buyer or seller of this propertyWhere is the home located?Maine (salt) waterfrontMaine lakefront or riverfrontOut of stateIn what town is the home located?So we can serve you more effectively and efficiently, please tell us which of our location(s) is most convenient for you.RocklandCamdenBelfastSouthwest Harbor (L.S. Robinson Co.)No preferenceAdditional comments or details?How did you learn about us?Search engineSocial mediaWord of mouthAdvertisingSeminar/trade showCAPTCHANameThis field is for validation purposes and should be left unchanged.
