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 - Goosehead Insurance - The Musico Agency. We are Multi-State Licensed... NV, CA, ID, NM, OH, and TN and through affiliations can take care of you in all U.S. States.
Licensed in NV, CA, ID, NM, OH, and TN and through affiliations can take care of you in all U.S. States.
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Step 1: Tell us about yourself
Full Legal Name
*
Date of Birth
*
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Month
-
Day
Year
Date
Social Security Number
Certain States require a SS# to obtain a fully rated quote with insurance carriers.
Driver's License Number
Please include the complete Driver's License number
Driver's License State of Issuance:
Please indicate from which State the drivers license was issued
Email (required for DocuSign)
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
I am...
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Single
Married
"Registered" Domestic Partnership
Separated
Divorced
Highest Level of Education Completed
*
High School / GED
Some College
Bachelor's Degree
Graduate School / Masters
Trade School
None
What is your current occupation?
*
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Step 2 - Additional Insured
If you will be purchasing this home with someone else on the title, or if you will have others residing in the home with you such as a spouse or registered domestic partner, please provide their information:
Full Name
First Name
Last Name
Date of Birth - Add'l Insured
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Month
-
Day
Year
Date
Social Security Number - Add'l Insured:
Driver's License - Add'l Insured
DL State of Issuance - Add'l Insured:
Please indicate the relationship of the Add'l Insured to you the applicant/insured:
Spouse
Registered Domestic Partner
Parent / Child / Sibling
Friend / Unrelated
Other
Education Level - Add'l Insured
High School / GED
Some College
Bachelors
Graduate School / Masters
Trade School
None
Current Occupation - Add'l Insured
Please include any other information about the additional insured that might be relevant. For example, is the person only temporarily in the home, or are there other occupants such as children.
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Step 3: Tell us about the home/purchase and your current living situation
Are you currently IN ESCROW to PURCHASE a NEW home?
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Yes
No
If yes, who is the Mortgage Loan Officer you are working with
Please provide name and Company they work for
Please provide your full and complete CURRENT Address:
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This is where you live now. Remember to include Unit or Apt Number if applicable
My current residence, I...
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Rent
Own
Please provide the PURCHASE address:
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This is the address of the new purchase you are making. Full Address including ZIp Code
What County is your NEW purchase located?
Please list county so we can review county assessor and building permit information.
Estimated Close of Escrow Date
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Month
-
Day
Year
Estimated Date you intend to close.
Are you a First Time Home Buyer?
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Yes - This is the first home I have ever purchased
No - I am purchasing a different home, and have owned other property(s) in the past.
This new purchase will be used as...
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Primary Residence
Secondary/Vacation Residence
Landlord with FT Tenant
Landlord with PT Tenant
AirBnB / Short Term Rental
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Describe your Home/Renters Claims History
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No property claims ever filed
No property claim filed in the Last 5 Years
Yes, I've filed for only 1 claim in the last 5 Years
Yes, I've filed 2 or more claims in the las 5 Years
Have you ever had a lapse in Homeowner's insurance?
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No - I have never had insurance lapse for non-payment, or cancellation
Yes - my insurance lapsed due to missed payment but was reinstated within 30 days
Yes - my insurance lapsed for more than 30 days
Not Applicable - I have never owned or rented real property.
Current Homeowner's Insurance Company
Please provide the name of your current insurance carrier... ex. State Farm, Allstate, Progressive, etc...
Current Homeowner's Insurance Liability Levels:
What is the current Personal Liability Limit carried on your current insurance policy. Ex. $300,000; $500,000; $1,000,000... etc.
Please provide the Declaration Page(s) from your current Homeowner's or Renter's Policy.
This document can be uploaded at the end of this form.
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How many occupants will reside in the home? Please include the total number of occupants (including you) and what relationship they are to you.
Please type number and relationship (i.e child, spouse, parent, sibling...)
How many occupants are under the age of 21?
Do you smoke or use tobacco products?
Yes
No
Do you own a Dog?
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Yes
No
What Breed is your dog?
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Please type breed. If a mixed breed, please include to the best of your knowledge the breeds. If you do NOT have a dog, plese type N/A
Has your dog ever bitten anyone in the past?
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Yes
No
Not Applicable
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Information about the Structure and Property:
What year was the Roof last replaced?
Please use your best estimate, or if you have an exact date, please provide it here.
What year was the Electrical System (breaker box and/or electric service to the home) updated?
Please use your best estimate, or if you have an exact date, please provide it here.
What year was the Plumbing (kitchen/bathroom, or other fixtures) updated in the home?
Please use your best estimate, or if you have an exact date, please provide it here.
What year was the HVAC system updated, replaced or refurbished?
Please use your best estimate, or if you have an exact date, please provide it here.
Is the property in good repair and free of neglected maintenance?
Yes
No
If there is neglected maintenance (i.e. this is a fixer upper), please describe what is not in good repair or neglected.
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We are able to provide a no cost service to help you get some of your utilities and services established at your new home. If you answer that you would like help, we will have this free service provider contact you to assist establishing some of your utility services at your new home.
This is an optional service at no charge to you, but is intended to be a convenience service to help establish new utility and other services in your new home.
Please check ALL that apply:
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I already have home security that is CENTRALLY MONITORED & will provide an alarm certificate for discounts
I will want a home security setup at my new place, but do not have one now.
I would like help getting my Home Security, Internet/TV setup at my new place
No thank you - I will contact all the utilities and service providers on my own.
It is important to fully protect your investment. Certain coverages are not included in a standard Homeowner's policy, but are available. Additional liability and financial protections are also available now that your overall personal worth has increased. We can help.
I am interested in... (check all that apply)
Jewelry coverage that extends beyond the basic coverage included in my Homeowners policy
Collections, Art, Classic/Collector Vehicle(s), Firearms and other belongings/investments beyond the basic coverage included in my Homeowner's policy.
information on Flood Insurance (Flood is not typically covered on Homeowner's Policies)
information on Earthquake Insurance (Earthquake Insurance is not covered on Homeowner's Policies)
information on a Personal Liability Umbrella policy to extend my liability coverage above the limits of my Homeowner's policy.
information on Life Insurance to help protect my new home purchase and/or provide my family financial peace of mind
Please provide any special notes or information that would be helpful or relevant for insuring your new purchase:
Please attach any receipts, appraisals, alarm certificates, current insurance declaration page(s), or other documents here:
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