The Balise Auto & Home Insurance Savings Programs Please enable JavaScript in your browser to complete this form. - Step 1 of 6Name *FirstLastBirthday *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email *Phone *Preferred Contact Method: *TextPhoneEmailNextMarital Status *SelectSingleMarried/Domestic PartnerDivorcedWidowedSeparated (Legally Married)Spouse Name *FirstLastSpouse Birthday *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PreviousNextQuotes of Interest *AutoHomeCondoRentersLandlord/RentalPersonal UmbrellaMobile HomeMotorcycleATV/Snowmobile/MopedPreviousNextResidence Type *ApartmentCondoDuplexMobile HomeSingle FamilyAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeTime at Address (Years) *Select12345678910 or morePrior Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePreviousNextCurrent Carrier *SelectAAAAllstateAmerican ModernAmicaAndoverArbellaASIBeacon MutualCommerceEMCEncompasseSuranceFarmersForemostGeicoLiberty MutualMain Street AmericaMapfreMotor ClubNational GeneralNationwideNBICNLCOhio MutualPeerlessProgressiveProvidence MutualQuincy MutualRI Auto PlanRIJRASafecoState FarmStillwaterThe HartfordTravelersUPCUSAAVermont MutualOther CarrierNot currently insuredCurrent Bodily Injury Limits *Select25,000/50,000 Bodily Injury50,000/100,000 Bodily Injury100,000 /300,000 Bodily Injury250,000/500,000 Bodily InjuryGreater than 250,000/500,000No PriorNumber of Vehicles *Select1234Vehicle Year, Make, Model 1 *Vehicle Year, Make, Model 2 *Vehicle Year, Make, Model 3 *Vehicle Year, Make, Model 4 *Other Licensed Household Members *None123Name *FirstLastDOB *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Marital Status *SelectSingleMarried/Domestic PartnerDivorcedWidowedSeparated (Legally Married)Relationship to Insured *SelectSpouseParentChildOther RelativeOther Non-RelativeName *FirstLastDOB *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Marital Status *SelectSingleMarried/Domestic PartnerDivorcedWidowedSeparated (Legally Married)Relationship to Insured *SelectSpouseParentChildOther RelativeOther Non-RelativeName *FirstLastDOB *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Marital Status *SelectSingleMarried/Domestic PartnerDivorcedWidowedSeparated (Legally Married)Relationship to Insured *SelectSpouseParentChildOther RelativeOther Non-RelativeNextDiscounts (Select all that apply) *AAA MemberAutomatic PaymentsCondo OwnerGo PaperlessHomeownerRenterEmployerPlease provide the name of your Employer to find out if you're eligible for additional discounts: *Any Accidents / Tickets / Violations / License Suspensions in the last 6 years? *YesNoYes, please describe * 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