• PL Intake Form

• Writing Agent*
  Please Select Angelina Fletcher Becky Fry Blaise Perrone Diane Labruto Erika Buck Jeremy Spiecker Katie Sheaffer Laurie Williams Mercedes Roth Mickie Shimp Steve Schappell Tori Jamison House Account
• Office Assigned*
  FleetwoodMorgantown
• Applicant Type*
  ProspectExisting Client
• Deal Type*
  New BusinessRequote
• Requote Reason*
• Marketing Source*
  Please Select Agent Effort BMI WebQuote BOP Brew Insur Web Brewers Event Carrier Forced Carrier: Erie Carrier: Progr Cli - NoPrompt DR - P&C Internal Refer Online Search Prior Client Prior Prospect REFERRAL Renewal Uprate REWRITE Signage Spin Off Walk In
• Source of Referral*
• Lines of Business to Quote*
  AutoHomeLife
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• Primary Insured

• Name*
  First NameLast Name
• Email*
  example@example.com
• Phone Number*
  Please enter a valid phone number.
• Permission to Text*
  YesNo
• DL#
• DL State
  Please Select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific
• Date of Birth*
   -Month -DayYear

  Date
• Gender*
  FemaleMale
• Education
  Please Select High School Some College Associates Degree Bachelors Degree Masters Degree Advanced Degree
• Industry
• Occupation
• Relationship Status*
  Please Select Single Married

• Spouse

• Spouse Name*
  First NameLast Name
• Spouse Email
  example@example.com
• Spouse Phone Number
  Please enter a valid phone number.
• Spouse - Permission to Text
  YesNo
• Spouse DL#
• Spouse DL State
  Please Select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific
• Spouse Date of Birth*
   -Month -DayYear

  Date
• Spouse Gender*
  FemaleMale
• Spouse Education
  Please Select High School Some College Associates Degree Bachelors Degree Masters Degree Advanced Degree
• Spouse Industry
• Spouse Occupation
• Property Address*
  Street Address

  Street Address Line 2

  City Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State

  Zip Code
• Is the mailing address the same as the property address?*
  YesNo
• Mailing Address
  Street Address

  Street Address Line 2

  City Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State

  Zip Code
• Have you lived at this address for 3 years or more?*
  YesNo
• Prior Address
  Street Address

  Street Address Line 2

  City Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State

  Zip Code
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• Do you currently have homeowners insurance?*
  YesNo
• Current Home Carrier*
• Do you currently have auto insurance?*
  YesNo
• Current Auto Carrier*
• Current Insurance Agency*
• Has their service been everything you expected?*
  YesNo
• Please explain why...
• Any problems/issues?*
  YesNo
• Please provide details...
• How many other agencies are you contacting for quotes?*
• Top two reasons for shopping...*
• OK with insurance score?*
  YesNo, Stop Process
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• Auto Insurance

• Requested Effective Date*
   -Month -DayYear

  Date

• Vehicle Information

• Household Vehicles*

• Driver Information

• Additional Household Drivers
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• Has any listed driver had their insurance cancelled in the past 5 years?*
  YesNo
• Has any listed driver been convicted of a DUI in the past 5 years?*
  YesNo
• Has any listed driver had their drivers license suspended or revoked in the past 5 years?*
  YesNo
• Has any listed driver had any comp claims, any accidents, or tickets of any kind in the past 5 years?*
  YesNo
• Accident Details
• Comp Loss Details
• Violations/Tickets
• Auto Qualify?*
  ProceedNot QualifyingNon-Std: No QuoteNon-Std: Progressive Only - Quote on First Call
• NOTES:
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• Auto Liability Coverage

• Liability Limits Type*
  Split LimitsSingle Limits
• Bodily Injury - Split Limits*
  Please Select 15,000 / 30,000 20,000 / 40,000 25,000 / 50,000 100,000 / 100,000 100,000 / 300,000 250,000 / 500,000 300,000 / 300,000 300,000 / 500,000 500,000 / 500,000 500,000 / 1,000,000 1,000,000 / 1,000,000
• Property Damage Liability*
  Please Select 5,000 10,000 25,000 50,000 100,000 200,000 250,000 300,000 500,000 1,000,000
• Single Limit Options*
  Please Select 35,000 100,000 300,000 500,000 750,000 1,000,000
• Tort*
  Please Select Limited Full
• UM Limits Type*
  Split LimitsSingle Limits
• UM - BI Split Limits*
  Please Select 15,000 / 30,000 20,000 / 40,000 25,000 / 50,000 100,000 / 100,000 100,000 / 300,000 250,000 / 500,000 300,000 / 300,000 300,000 / 500,000 500,000 / 500,000 500,000 / 1,000,000 1,000,000 / 1,000,000
• UM - BI Single Limits*
  Please Select 35,000 100,000 300,000 500,000 750,000 1,000,000
• Stack UM Limits*
  YesNo
• UIM Limits Type*
  Split LimitsSingle Limits
• UIM - BI Split Limits*
  Please Select 15,000 / 30,000 20,000 / 40,000 25,000 / 50,000 100,000 / 100,000 100,000 / 300,000 250,000 / 500,000 300,000 / 300,000 300,000 / 500,000 500,000 / 500,000 500,000 / 1,000,000 1,000,000 / 1,000,000
• UIM - BI Single Limit*
  Please Select 35,000 100,000 300,000 500,000 750,000 1,000,000
• Stack UIM Limits*
  YesNo
• Medical Payments*
  Please Select 5,000 10,000 25,000 50,000 100,000
• Income Loss*
  Please Select No Coverage 1,000/Month - 5,000/Max 1,500/Month - 15,000/Max 1,500/Month - 25,000/Max 2,500/Month - 50,000/Max 5,000/Month - 100,000/Max
• Accidental Death*
  Please Select No Coverage 5,000 10,000 25,000
• Funeral*
  Please Select No Coverage 1,500 2,500
• NOTES:
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• Homeowners Insurance

• Policy Type*
  HomeCondoTenantManufactured
• Risk Status*
  Occupied by Applicant & InsuredBeing PurchasedSecondary Home/RentalOccupied by Applicant & UninsuredUnder Construction
• Purchase Date or Renters Move-In Date
   -Month -DayYear

  Date
• Residence Type*
  PrimarySecondaryRented to OthersMiscellaneous Property
• Year Built
  Please Select 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925
• Approximate Square Footage
• Number of Families*
  12Other
• Dwelling Type*
  Please Select Colonial Bi-Level Row-End Townhouse-End Cape Cod Contemporary Ranch Split-Level Row-Mid Townhouse-Mid
• Construction*
  Please Select Frame Stone Stone Veneer Fire Resistive Log Brick/Masonry Brick/Masonry Veneer
• Materials*
  Please Select Standard Asbestos EIFS
• Protection
  Smoke DetectorFire ExtinguisherDead-Bolt(s)SprinkleredCentral BurglarCentral FireLocal Alarm OnlyVisible to NeighborsGated Community
• Number of Full Baths
• Number of Half Baths
• Garage
  Please Select None 1-car Attached 2-car Attached 3-car Attached 4-car Attached 1-car Detached 2-car Detached 3-car Detached 4-car Detached
• Basement
  YesNo
• Finished
  YesNo
• Walkout
  YesNo
• Sump Pump
  YesNo
• Power Backup
  YesNo
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• Homeowners Insurance

• Deck
  YesNo
• Deck Type
  WoodCompositeOther
• Deck Square Footage
• Distance to Fire Hydrant*
  <1,000 ft>1,000 ftNone
• Distance to Fire Station*
  <5 miles6-10 milesNone
• Total Occupants*
• Occupants Under 18*
• Year of last Roof Replacement*
  Please Select 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925
• Roof Shape*
  PeakedFlat
• Roof Material*
  Please Select Architectural 3Tab Metal Slate Wood Shake Other
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• Homeowners Insurance

• System Updates*
  NoneHeatingPlumbingElectrical
• Heating Update Details*
• Plumbing Update Details*
• Electrical Update Details*
• Cooling System*
  CentralWindow Unit(s)Other
• Number of Window Units*
• Primary Heating System*
  ElectricGasOilOther
• Oil Tank Location*
  Please Select None Underground Above Ground Indoors Above Ground Outdoors
• Oil Tank Age*
  Please Select 30 or less years old 31 to 50 years old More than 50 years old
• Fireplace*
  YesNo
• Number of Wood Fireplaces
• Number of Gas Fireplaces
• Wood Pellet Stove*
  YesNo
• Professionally Installed*
  YesNo
• Wood Pellet Stove - Type & Location*
• Wood Pellet Stove - Frequency of Cleaning*
• Do you have any household pets?*
  YesNo
• Pet Details*
• Swimming Pool*
  YesNo
• Above Ground*
  YesNo
• Diving Board*
  YesNo
• Fenced*
  YesNo
• Acreage*
  <12-56-10>10
• Acreage Details
• NOTES:
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• Homeowners Insurance

• Home Closing?
  YesNo
• Mortgage Amount
• Purchased as foreclosure or short sale?
  YesNo
• Any business or daycare?*
  YesNo
• Business / Daycare Details*
• Any HOA or Condo Association?
  YesNo
• HOA / Condo Association Details*
• Current or Preferred Payment Plan*
  EscrowedFull PayPayment Plan
• Auto Policy BI Limits (needed for Progressive Home Discounts)
  Quoting Auto, see checklistOther Company AutoNo Prior AutoProgressive Auto <50/100Progressive Auto =50/100Progressive Auto =100/300Progressive Auto =250/500
• Current Home Policy*
  Prior Decs ReceivedAwaiting Prior DecsN/A - Home ClosingDetails Entered Below
• Current Coverage Limits

  	Amount
  Dwelling Limit
  Personal Property Limit
  Liability Limit
  Medical Payments Limit
  Deductible
  Current Premium
• Special Coverage Endorsements
  Guaranteed Replacement Cost150% Replacement Cost125% Replacement Cost100% Replacement CostReplacement Cost ContentsScheduled Personal PropertyEquipment BreakdownPersonal Cyber LiabilityWater Back-upIdentify TheftPersonal InjuryLoss AssessmentOrdinance or LawBusiness PursuitsSinkholeEarthquakeFloodOther
• Dwelling Replacement Cost*
  Guaranteed Replacement Cost150% Replacement Cost125% Replacement Cost100% Replacement Cost
• Scheduled Personal Property*
• Water Backup Limit*
  $5,000$10,000$25,000Other
• NOTES:
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• Life Insurance

• Applicant Information*
• NOTES:
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• Final Notes/Comments
• SaveSubmit
• Should be Empty: