Producer Intake Form
Name of person completing this form:
*
First Name
Last Name
Name of producer, if different:
First Name
Last Name
New or existing client?
*
New Customer
Existing Customer
Customer Type:
*
Commercial
Personal
Life
Lead Distribution:
*
Assign lead to PL sales
Assign lead back to producer for quoting
Lead Distribution:
*
Assign lead to CL sales
Assign lead to specific CL CSR
Assign lead back to producer for quoting
Enter name of CSR:
*
First Name
Last Name
Contact with client:
*
Producer to contact client with questions
CSR to contact client directly with questions
Present quotes
*
Producer to present quotes to prospect
CSR to present quotes to prospect
Originating Office:
*
Risman - Medford
Byette - Tewksbury
A&K Fowler - Tewksbury
Hurley - Danvers
Phil Richard - Danvers
Delaney - Dorchester
TF Ward - Melrose
Insurance Associates - Burlington
Coughlin - Dracut
LTB - Burlington
Commercial
Entity Name:
*
DBA:
FEIN:
Website:
Premium Size:
Under $5,000
$5,001 - $50,000
Greater than $50,000
Description of operations:
*
Next Expiration Date:
/
Month
/
Day
Year
Annual Revenue ($):
Annual Employee Payroll ($):
Annual Subcontracted Work ($):
Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Formal Salutation:
*
(First and Last Name)
Informal Salutation:
*
(Nickname or First Name)
Email 1:
Email 2:
Phone Numbers
Phone Numbers
Residence:
Business:
Fax:
Cell:
Pager:
Other:
Select each line of business that will be quoted:
*
Commercial Package
Business Owners
General Liability (Monoline)
Commercial Property (Monoline)
Commercial Auto
Workers Compensation
Commercial Umbrella
Other
Additional Information (if any):
File Upload (if any):
Browse Files
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Choose a file
Cancel
of
Print
Submit
Personal
Client Name:
*
First Name
Last Name
Second Name: (if any)
First Name
Last Name
Select each line of business that will be quoted:
*
Personal Auto
Homeowners
Condo Unitowner
Tenant
Dwelling Fire
Personal Umbrella
Builder's Risk
Flood
Jewelry
Life
Mobile Home
Motorcycle
Seasonal Home
Tenant
Travel Trailer
Vacant Home
Valuables
Watercraft
Other
Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Formal Salutation:
*
(First and Last Name)
Informal Salutation:
*
(Nickname or First Name)
Email 1:
Email 2:
Phone Numbers
Phone Numbers
Residence:
Business:
Fax:
Cell:
Pager:
Other:
Additional Information (if any):
File Upload (if any):
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Print
Submit
Should be Empty: