Auto Intake Form

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Agent Intake Form - Let's get some basic information!
Agent Name*
Select the name of the agent this quote information is for.
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date of birth
Marital Status
Gender

MaleFemale
Do you currently have auto insurance?

YesNo
If so, what company/carrier?
Example: Progressive w/ Don Bullard or just Progressive, Nationwide or National General
Insurance Renewal Date
Fill the exact date or month range
Any auto claims or losses in the last 5 years?

YesNo
Notes
Add any relevant information

Client Support Name
Fill this if you are a client support team member filling this form
Where do you currently reside?

Fill out the basic information below
Current Address

Street Address

Street Address Line 2

CityState

Zip Code
How long have you lived at your current address?

Less than 3 years3 years or more
Notes
Add any relevant information

Add Another Driver

Please fill out the additional driver information.
First Name
Last Name
Email
(If necessary)
Phone Number
(If necessary)
Date of Birth

MonthDayYear
Date of birth
Marital Status
Gender

MaleFemale
Do they currently have auto insurance?

YesNo
If so, what company/carrier?
Example: Progressive w/ Don Bullard or just Progressive, Nationwide or National General
Drivers License Number
Driver's License State
Example: NC, SC or North Carolina, South Carolina
Age Licensed
Notes
Add any relevant information

Let's get some details about your vehicle

Please provide this information to the best of your ability
VIN
Year
Example: 2005, 2010, 2015
Make
Example: Honda, Audi, Acura, Ford
Model
Example: Civic, E-Tron, Bronco, Explorer
Body Style
Do you want to add another vehicle?*

YesNo
Notes
Add any relevant information

Add another vehicle

Please provide this information to the best of your ability
VIN
Year
Example: 2005, 2010, 2015
Make
Example: Honda, Audi, Acura, Ford
Model
Example: Civic, E-Tron, Bronco, Explorer
Body Style
Notes
Add any relevant information

How do you primarily use your vehicle(s)

This helps us understand the wear and tear annually
Annual Miles Driven
Example: 5,000, 10,000, 15,000, 20,000, etc.
Primary Use Of Vehicle
Example: Business, Farming, To/From Work, etc.
Commute Miles One Way
Example: 10, 15, 20, 30, etc.
Number Of Days Driven Per Week
Example: 1 day, 2 days, 3 days, etc.
Number Of Weeks Driven Per Month
Example: 1 week, 2 weeks, 3 weeks, 4 weeks.
Notes
Add any relevant information

What are your current or desired auto coverages?

The coverage limits on your policy are important to help get you the most accurate rate.
Comprehensive Deductible
For non-collision damages
Collision Deductible
For collision damages
Towing & Labor Coverage
For roadside help
Rental Car Coverage
For rental cars during repairs.
Notes
Add any relevant information

Do you want any of the following coverages?

If you need more coverage explanation, please ask.
Bodily Injury
Medical costs for everyone but you
Uninsured Motorist
Covers if someone doesn't have insurance
Underinsured Motorist
Costs not covered by other's insurance
Property Damage
Costs for damages to other's vehicle and property
Medical Payments
Medical costs for people within your vehicle
Notes
Add any relevant information

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