New Client Intake Form - Nicole Makin

1
Your Name
First Name
Last Name
2
Your Gender
3
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Country
4
Email
example@example.com
5
How did you hear about us?
Someone Referred Me
Google
Facebook
YouTube
LinkedIn
Reddit
Other
6
Who referred you to us?
7
If you clicked "other," how did you hear about us?
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8
Cell Phone Number
Area Code
Phone Number
9
Your Date of Birth* This field is required.
Date
Month
Day
Year
10
Your Driver's License Number (please specify the state)* This field is required.
11
Highest Level of Education
Please Select
Please Select
No High School Degree
High School Degree
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
Doctorate Degree
PhD
Law Degree
12
Occupation
13
Marital Status
Please Select
Please Select
Single
Domestic Partner
Married
Separated
Divorced
Widowed
14
Partner's Name* This field is required.
First Name
Last Name
15
Partner's Date of Birth
Date
Month
Day
Year
16
Partner's Driver's License Number* This field is required.
17
Partner's Highest Level of Education
Please Select
Please Select
No High School Degree
High School Degree
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
Doctorate Degree
PhD
Law Degree
18
Partner's Occupation
19
Current Auto Insurance Company:
20
Year, make and model of vehicles:
Year
Make
Model
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Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
1
2
3
4
Year
Row 0, Column 0
Make
Row 0, Column 1
Model
Row 0, Column 2
Year
Row 1, Column 0
Make
Row 1, Column 1
Model
Row 1, Column 2
Year
Row 2, Column 0
Make
Row 2, Column 1
Model
Row 2, Column 2
Year
Row 3, Column 0
Make
Row 3, Column 1
Model
Row 3, Column 2
1 of 4
21
Other drivers on the policy?
YESNO
22
If YES, we need legal name, date of birth, driver's license number and relation to you:
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Ok
23
What kind of home do you live in?
Single Family Home
Rent a house or apartment
Condo
Manufactured/mobile home
Multi-family home
Other
24
Tell us about your home:
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Small
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Ok
25
Is this a new home purchase?
YESNO
26
What is the target closing date?
Date
Month
Day
Year
27
Year of Last Roof Replacement:
Please Select
Please Select
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005 or older
28
Roofing Material:
Please Select
Please Select
Asphalt 3-Tab
Metal
Poured
Slate
Tile
Wood
Flat/Gravel/Tar/Rolled
Hail Resistant
Asphalt Architectural
Other
Unknown
29
What floor is your condo located on? (1st, 2nd, 3rd, below level, etc)
30
How many units are above your condo unit?
31
How old is your home?
0-20 years old
21+ years old
32
Home Foundation Type:
Please Select
Please Select
Basement
Shallow Basement
Concrete slab
Crawlspace
Other
33
Approximately what % of your basement is finished?
Please Select
Please Select
100%
75%
50%
25%
0%
34
Please describe your home's foundation:
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Small
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Ok
35
Do you have any dogs?
YESNO
36
How many dogs do you have, and what are their breeds?
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Small
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Ok
37
Do you have a swimming pool?
YESNO
38
Please confirm your pool's details:
Please Select
Please Select
In-ground unfenced without slide/diving board
In-ground unfenced with slide/diving board
In-ground fenced without slide/diving board
In-ground fenced with slide/diving board
Above ground unfenced without slide/diving board
Above ground unfenced with slide/diving board
Above ground fenced without slide/diving board
Above ground fenced with slide/diving board
39
Do you have a trampoline?
YESNO
40
Please confirm your trampoline's details:
Please Select
Please Select
Trampoline is netted and fenced
Trampoline is unnetted and fenced
Trampoline is netted and unfenced
Trampoline is unnetted and unfenced
41
Do you have an alarm system?
YESNO
42
Is it monitored by a security company?
YESNO
43
What has you looking for new insurance?
Please Select
Please Select
Price
Coverage
Service
44
Is there anything additional you want us to know?
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Should be Empty: