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The information we request on this form provides a starting place for a personal conversation about the 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.

If you are human, leave this field blank.

First Name

Last Name

Address

Email

Phone

Preferred method of contact

Email

Phone

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 plan

Coverage as part of a spouse or partner's plan

Other

Do you travel often and need coverage that travels with you?

Yes

No

Please tell us what you want most in a Medicare plan.

Overall cost

I don't mind copays if my monthly premium is lower

I would consider switching to a doctor in a plan's network

I'm comfortable getting a referral to see a specialist

I would go to a retail chain to fill my prescriptions

I would prefer to use a mail order pharmacy

I could use help managing chronic, recurring medical conditions or health issues

Having dental and vision coverage is important to me

Are you interested in discussing any specific Medicare plans or carriers?

Yes

No

There is no substitute for a personal conversation.
This form will help us get started creating a business insurance quote for you.

Whenever possible, we will 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.

If you are human, leave this field blank.

Name (required) *

First

Last *

Last

Phone number (xxx-xxx-xxxx) *

Required field

Email

How do you prefer to be contacted? (please choose at least one)

Phone

Email

Business name

Type of business

Contractor

Retailer

Professional Services

Non-Profit

Other (please use field below to describe)

Please tell us the type of business insurance coverage you are interested in.

Commercial Package

Commercial Property

Commercial Auto

Workers Compensation

Bond

Liability Insurance

Cyber Risk

Other (please use field below to describe)

What type of insurance are you interested in?

So we can serve you more effectively and efficiently, please tell us which of our locations is most convenient for you.

Rockland

Camden

Belfast

Southwest Harbor (L.S. Robinson Co.)

No preference

Required: We need to know where your business is located (what state?). *

Required: How did you find out about us? (choose one) *

Web search

WorkBoat Magazine

Referral

Seminar/trade show

Advertisement

OtherOther

Additional details

There is no substitute for a personal conversation.
This form will help us get started creating 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.

If you are human, leave this field blank.

Name (required) *

First

Last *

Email

Phone number (xxx-xxx-xxxx) *

Required field

How do you prefer to be contacted?

Phone

Email

Is this property

Your primary residence

A vacation home/secondary residence

Are you ...

The owner of this property

A prospective buyer of this property

An agent of the buyer or seller of this property

Where is the home located? (please specify town in the space below)

Maine (salt) waterfront

Maine lakefront or riverfront

Out of state

Additional information

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.

If you are human, leave this field blank.

Name (required) *

First

Last Name *

Last

Phone number (xxx-xxx-xxxx) *

Required field

Email

How do you prefer to be contacted? (please choose at least one)

By Phone

By Email

Please tell us the type of insurance you are interested in.

Boat/Yacht

Marina/Boatyard

Commercial Vessel Operation

Crew Health Insurance

Yacht Club

Other

What type of insurance are you interested in?

Required: How did you find out about us? (choose one) *

Web search

WorkBoat Magazine

Referral

Seminar/trade show

Advertisement

OtherOther

Comments

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.

If you are human, leave this field blank.

Name (required) *

First

Last Name *

Last

Email

Phone number (xxx-xxx-xxxx) *

Required field

How do you prefer to be contacted?

Phone

Email

What kind of life insurance would you like?

Term Life

Whole Life

Universal Life

Not Sure

Additional comments/information *

There is no substitute for a personal conversation.
This form will help us get started creating a personal 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.

If you are human, leave this field blank.

Name (required) *

First

Last *

Last

Phone number (xxx-xxx-xxxx) *

Required field

Email

How do you prefer to be contacted?

Phone

Email

What type of insurance are you interested in?

Homeowners

Auto

I'd Like a Complete Insurance Review

Umbrella Insurance

Boat & Yacht

Motorcycle

Life

Health

Travel/Trip

Flood

Other (describe in box below)

So we can serve you more efficiently, please tell us which of our locations is most convenient for you.

Rockland

Camden

Belfast

Southwest Harbor (L.S. Robinson Co.)

Portland

Additional details

There is no substitute for a personal conversation.
This form will help us get started creating a 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, 2019. Until the next open enrollment period, you can enroll only under a special exception, for which we refer you to healthcare.gov

If you are human, leave this field blank.

Name (required) *

First

Last *

Last

Phone number (xxx-xxx-xxxx) *

Required field

Email *

Current customer of Allen Insurance and Financial? *

Yes

No

How do you prefer to be contacted?

Phone

Email

Please tell us the type of insurance you are interested in.

Short-Term Medical

Life or Disability

Group Health for Business

Medicare

Travel Medical

Trip

Additional information

There is no substitute for a personal conversation.
This form will help us get started creating a travel or trip 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.

If you are human, leave this field blank.

Title (optional) Please select Mr. Mrs. Ms. Miss Dr.

Name (required) *

First

Last *

Last

Phone number *

Required: xxx-xxx-xxxx

Email

How do you prefer to be contacted?

Phone

Email

Please choose at least one.

Ages today of all who are traveling with you (separate by comma)

(This helps us get the most accurate quote possible)

Date of departure (must be within 15 months of today to get a quote)

mm/dd/yy

Date of return

mm/dd/yy

Where are you traveling?

Non-refundable cost of your trip? *

Required: We cannot provide a quote without this information.

Date of initial non-refundable deposit?

Your state of residence

Your zip code

How did you find us?

Web search

Referral from Bar Harbor/Acadia Cottage Rentals

Referral from another website (please provide info in box below)

Personal Referral/Friend (please provide info in box below)

Name of other website or personal referral

Thank you for providing us with this information. We like to say thank you to the people and businesses that refer customers to us.

There is no substitute for a personal conversation.
This form will help us get started creating a health 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.

If you are human, leave this field blank.

First Name *

First

Last Name *

Last

Phone Number (xxx-xxx-xxxx) *

Email

Preferred method of contact (please choose one)

Phone

Email

Lake Association You Represent/Are Inquiring For

Additional Information/Questions