At Goosehead Insurance...
We believe in always doing what's best for our clients. If price is most important, we'll make it happen. If coverage is more important, you're at the right place. If both are important to you, we're totally on the same page! Please complete the short intake form so we can shop the best overall options for you. Thank you! -Nick Ramirez ~ CA License # OK79987
Step 1: Tell Us About Yourself :)
After we gather your info, we'll shop over 25+ A rated companies for the best deal!
Full Legal Name:
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Date of Birth
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Month
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Day
Year
Date
Cell Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email (for DocuSign)
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example@example.com
Job Title & Occupation
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Used to source more discounts for you :)
I am...
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Single
Married
Spouse Legal Name
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Spouse Date of Birth
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Month
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Day
Year
Date
Spouse Job Title & Occupation
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Are you currently IN ESCROW to PURCHASE a NEW home?
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Yes
No
What is your **FULL & COMPLETE** current address?
Remember to include UNIT or APT if needed*
Please confirm the PURCHASE address:
FULL address WITH zip code*
Estimated Close of Escrow Date
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Month
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Day
Year
Date
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Property Claim History
Describe Your Property Claim History
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No property claims filed ever
No property claims filed in the last 5 years
Yes, I've filed only 1 claim in the last 5 years
Yes, I've filed 2-3 claims in the last 5 years
Got it. 3 things we need to know. Date of Loss, Total Paid Out & What Happened.
As much info as you can provide is very helpful.
Do you own any dogs?
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Yes
No
Do you own ANY of the following dog breeds? Akita, Alaskan Malamute, Chow Chow, Doberman Pinscher, Husky, Mastiff, Pit bull, Presa Canario (canary dog), Rottweiler, and Wolf dogs and hybrids.
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No
Yes
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Please check ALL that apply:
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I already have home security & will provide proof for discounts
I will want home security setup at my new place (Vivint, ADT, etc)
I will want Internet/TV setup at my new place (Spectrum, Direct TV, etc)
I have jewelry and it's already insured elsewhere
I have jewelry but it's not insured
None
Please attach any jewelry receipts/appraisals or proof of alarms:
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Any Special Notes or Situations You'd Like Us To Know?
Who referred you? We'd love to reach out and say thank you!
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