Home insurance intake form

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! -Philip Miles / CA Lic #0K93165, AZ Lic #17963684
Step 1: Tell Us About Yourself :)

After we gather your info, we'll shop over 25+ A rated companies for the best deal!
Legal Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Cell Phone Number *
Please enter a valid phone number.
Email*
example@example.com
I am...*

SingleMarried
Spouse Legal Name *

First NameLast Name
Spouse Date of Birth *

MonthDayYear
Date
Spouses Cell Phone Number
Please enter a valid phone number.
Spouses Email
example@example.com
What is your CURRENT address? *

Street Address

Street Address Line 2

CityState

Zip Code
Why are you currently shopping for home insurance? (rates, cancellation or non-renewal, multiple claims, previous policy cancellation date, etc)
* Please be specific as possible as this can affect availability and prices of a new policy
Are you currently in Escrow to PURCHASE a new home?*

YesNo
Please confirm the PURCHASE address:

Street Address

Street Address Line 2

CityState

Zip Code
Estimated Close of Escrow Date and/or start date needed for new insurance?*

MonthDayYear
Date
What is the expiration date of your current policy?*

MonthDayYear
Date
What Carrier are you currently insured with?*
What is the annual rate you are currently paying for your policy?*
Please put the closet rounded $ amount
What is the square footage of your new home?
Will you be renting any part of your home?*
What is your occupation? *
What is your spouses' occupation?
Claim History
Describe Your Property Claim History*

No property claims filed everNo property claims filed in the last 5 yearsYes, I've filed only 1 claim in the last 5 yearsYes, I've filed 2-3 claims in the last 5 years
What year was the roof upgraded/ replacedYear*
What year was the plumbing upgraded/replaced Year*
What year was the electrical upgraded/ replacedYear*
*Please Estimate update year to the best of your knowledge or put year built
While we're at it, are you open minded to shopping your auto insurance policy?*

Yeah, if it takes like 5 minutes to check, sure!No thanks, I've shopped my insurance rate at least once in the last 3 years.
Do you have ANY of the following in your home? Please check ALL that apply:*

DogsI already have monitored Burglar and/or Fire Alarms (ADT, Vivient, etc)I will want or need monitored Burglar and/or Fire Alarms (ADT, Vivient, etc)Jewelry between 1k-5kJewelry over 5kNone of the above
Please attach any jewelry receipts/appraisals or proof of alarms:

Cancelof
What is the full name of who referred you? We'd love to reach out and say thank you!
Should be Empty:

At Goosehead Insurance...

Step 1: Tell Us About Yourself :)

Claim History