Personal Lines Intake Form
Please fill the form accurately for better assistance
How did you hear about us? Were you referred by anyone?
*
Please Select
Website
Google
Referral
What is the name of the person who referred you? We would like to send them a quick thank you.
Lines of business to be quoted:
*
Home
Condo
Renters
Auto
Umbrella
Valuable Articles
Rec Vehicle / Motorcycle
Boat
Motorhome
Other
When do you need this quote returned by?
*
 -
Month
 -
Day
Year
Date
Customer Info
Primary Insured Name
*
First Name
Last Name
Primary Insured Date of Birth:
*
 /
Month
 /
Day
Year
Date
Relationship Status
*
Married
Single
Widowed
Divorced
Domestic Partner
Other
Other Named Insured
First Name
Last Name
Other named Insured Date of Birth
 /
Month
 /
Day
Year
Date
Primary E-mail
*
example@example.com
Primary Insured Cell
*
Customer gave permission to text this number:
*
Yes
No
Primary Insured Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When does your current insurance expire?
*
 /
Month
 /
Day
Year
Date
Set appointment for quote review?
*
Yes
No
Agent/CSR appointment setting process
1. Use the Following Info to complete the scheduling link
Customer Name:Â {primaryInsured}
Call Back Number: 636-706-5660
Quotes Requested:Â {linesOf}
Â
Umbrella Coverage
Limit Requested
*
Please Select
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Do you want UM/UIM coverage?
*
Yes
No
Valuable Articles
Valuable Articles List
*
Rows
Amount
Description
Appraisal Attached
Item 1
Item 2
Item 3
Desired Ded.
*
Attach Appraisal(s)
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of
Watercraft
Watercraft Info
*
Rows
Year / Make / Model
Hull Number
Motor Yr/Make
Max Speed
HP or CC
Trailer amount
Watercraft 1
Watercraft 2
Rec Vehicle / Motorcycle
Rec Vehicle / Motorcycle Driver Info
*
Rows
Name / Relationship
DOB
Drivers License
Driver 1
Driver 2
Driver 3
Rec Vehicle / Motorcycle Info
*
Rows
Year/Make/Model
Serial Number
Value
CC / HP
Vehicle 1
Vehicle 2
Rec Vehicle / Motorcycle Liability Limits
*
Rows
Limits Requested
Liability Limits - Suggested 100/300
Property Damage - Suggested 100
Medical
UM - Suggested 100/300
UIM - Suggested 100/300
Comp Ded - Suggested $1,000
Coll Ded - Suggested $1,000
Other Not Listed - Document Coverage needed
Do any of the Rec Vehicle / Motorcycle have a loan or lease
*
Yes
No
Auto Questions
Auto Driver Info
*
Rows
Name / Relationship
DOB
Drivers License
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5
Driver 6
Vehicle Info
*
Rows
Year/Make/Model
Vin
Deductible
Usage
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Do any of the Vehicles have a loan or lease
*
Yes
No
Do you use any of these vehicles in the course of business?
*
Yes
No
List Vehicle Number - How is this vehicle used in the course of business?
Preferred Vehicle Liability Limits
*
Rows
Limits Requested
Liability Limits - Suggested 100/300
Property Damage - Suggested 100
Road Side - Included, can remove after review
Medical
UM - Suggested 100/300
UIM - Suggested 100/300
Comp Ded - Suggested $1,000
Glass - Included, can remove after review
Coll Ded - Suggested $1,000
Other Not Listed - Document Coverage needed
Available discounts discussed with prospect
Good Student
Low Milage
Occupation Discount
Other
Supporting discount documents:
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Condo Quote
Coverage Options
*
Rows
Limits Requested
Personal Property Coverage
Structure Coverage
Water/Sewer - Included, $25,000
Personal Injury - Included, can remove after review
ID Theft - Included, can remove after review
Policy Deductible
Loss Assessment Coverage Amount
Renters Questions
Coverage Options
*
Rows
Limits Requested
Personal Property Coverage
Water/Sewer - Included, $25,000
Personal Injury - Included, can remove after review
ID Theft - Included, can remove after review
Policy Deductible
Home Questions
Home details
*
Rows
Home Details
Year Built
Construction Type (Brick, Frame, Stucco...)
Roof Material
Total square footage (excluding basement)
# of Stories
# of Bathrooms
Foundation Type & Percent Finished
Garage (# of Bays / Attached or Detached)
Updates to Electric, HVAC or Plumbing
Fireplace or Chimney
Updates to property
*
Rows
Limits Requested
Roof year
Plumbing Year & Full or Partial
Electrical Year & Full or Partial
HVAC Year & Full or Partial
Coverage Options
*
Rows
Limits Requested
Earthquake
Water/Sewer - Included, $25,000
Personal Injury - Included, can remove after review
Valuable Articles - Included, can remove after review
Service Line Coverage
Dog or Exotic Pet on premise
*
Yes
No
Any known bite history?
*
Yes
No
Provide pet details here, breed or type of pet:
*
If unknown please use customers best guess
Are you aware of any claims in the last 3 years?
*
Yes
No
Is their a mortgage on the home?
*
Yes
No
Is this home in a Trust or LLC?
*
Yes
No
Attachments & Notes
Attachments to save to the account:
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of
Notes on the account:
Submit Form
Should be Empty: