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 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. 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 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.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 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.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 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.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 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.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 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.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 2021 closed on Dec. 15, 2020. 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. Whenever possible, we’ll be in touch the next business day for all forms submitted. A trip insurance policy covers the non-refundable costs of your trip if you’re unable to take your vacation or have to interrupt your trip and come home early. The coverage automatically embeds some extras like medical coverage, lost baggage, and missed connection benefits. IMPORTANT NOTICE: A Cancel for Any Reason benefit is an upgrade which requires purchase of a Preferred-level plan and carries additional cost. This benefit must be purchased within 10 days of making your initial trip deposit for any aspect of your trip, be it lodging, a car rental or reservations for travel. A Cancel for any Reason benefit allows you to cancel for any reason not listed on the Certificate of Coverage and you’d receive a 75% refund of your insured amount. Cancellation due to travel restrictions or other circumstances related to the Coronavirus are not a covered reason to cancel under these plans unless you have the Cancel for Any Reason benefit. However, illness, as certified by a doctor, may be a covered reason for cancellation. Please read your plan documents carefully and be aware that this benefit is not available for residents of the states of New Hampshire, New York and Washington. This form will help us start a travel or trip insurance quote for you. Whenever possible, we’ll be in touch the next 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. IMPORTANT NOTICE: A trip insurance policy covers the non-refundable costs of your trip if you’re unable to take your vacation or have to interrupt your trip and come home early. The coverage automatically embeds some extras like medical coverage, lost baggage, and missed connection benefits. A Cancel for Any Reason benefit is an upgrade which requires purchase of a Preferred-level plan and carries additional cost. This benefit must be purchased within 10 days of making your initial trip deposit for any aspect of your trip, be it lodging, a car rental or reservations for travel. A Cancel for any Reason benefit allows you to cancel for any reason not listed on the Certificate of Coverage and you’d receive a 75% refund of your insured amount. Cancellation due to travel restrictions or other circumstances related to the Coronavirus are not a covered reason to cancel under these plans unless you have the Cancel for Any Reason benefit. However, illness, as certified by a doctor, may be a covered reason for cancellation. Please read your plan documents carefully and be aware that this benefit is not to residents of the states of New York, New Hampshire and Washington. 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 AfghanistanAlbaniaAlgeriaAmerican 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 RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 AfghanistanAlbaniaAlgeriaAmerican 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 RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 showCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
