New Client Intake Form

New Client Intake Form

Home, Auto, & Recreational Insurance
Thank you for choosing to work with our agency!
We truly appreciate the opportunity to work with you. This short form will help us better understand your needs so we can provide personalized coverage options that fit your lifestyle or business.

Your information is secure and will only be used for quoting and communication purposes. You can learn more about how we handle your information, by reading through our privacy policy at the bottom of this form. If you have any questions at any point, don’t hesitate to reach out — we’re here to help every step of the way.

We look forward to earning your trust and helping you protect what matters most in life.

Sincerely,

Kai Marder

Independent Insurance Agent/ Founder
Aurora Insurance Solutions LLC
Personal Information

Please complete all sections of this form to allow us to provide you with the most accurate insurance quote. Not providing accurate information can result in policy premium changes once the policy goes through Underwriting. This is important as the Carriers will pull Credit and BMV Records. Thank you for your cooperation. (If a field does not apply please leave that field blank) Please refer to our privacy policy below to learn more about how we handle your private information.
Full Legal Name:

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth:

MonthDayYear
License Number/State:
Social Security Number:
Residential Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
E-mail:
example@example.com
Do you currently have insurance?

YesNo
If yes, with whom?
Policy Numbers:
How did you hear about us?
Please Specify:
Home/ Renters Insurance

Please provide the following information for each Property to be insured.
Property 1 Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you Rent or Own:
Type of Residence: (Single-Family, Condo, Townhouse, etc.
Year Built:
Square Footage:
Age of Roof:
Basement:

YesNo
Security System:

YesNo
Swimming Pool:

YesNo
Trampoline:

YesNo
Animals/Breed: (e.g., Dog/German Shepard mix)
Mortgage Company/ Lien Holder:
Property 2 Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you Rent or Own:
Type of Residence: (Single-Family, Condo, Townhouse, etc.
Year Built:
Square Footage:
Age of Roof:
Basement:

YesNo
Security System:

YesNo
Swimming Pool:

YesNo
Trampoline:

YesNo
Animals/Breed: ex dog/german shepard mix
Mortgage Company:
Auto Insurance

Please provide the following information for each vehicle:
Vehicle 1
Year:
Make:
Model:
VIN Number:
Primary Use: (Commute, Pleasure, Business, ect.):
Estimated Annual Mileage:
Driver(s) of this vehicle:
Lienholder:
Vehicle 2
Year:
Make:
Model:
VIN Number:
Primary Use: (Commute, Pleasure, Business, ect.):
Estimated Annual Mileage:
Driver(s) of this vehicle:
Lienholder:
Vehicle 3
Year:
Make:
Model:
VIN Number:
Primary Use: (Commute, Pleasure, Business, ect.):
Estimated Annual Mileage:
Driver(s) of this vehicle:
Lienholder:
Vehicle 4
Year:
Make:
Model:
VIN Number:
Primary Use: (Commute, Pleasure, Business, ect.):
Estimated Annual Mileage:
Driver(s) of this vehicle:
Lienholder:
Vehicle 5
Year:
Make:
Model:
VIN Number:
Primary Use: (Commute, Pleasure, Business, ect.):
Estimated Annual Mileage:
Driver(s) of this vehicle:
Lienholder:
Vehicle 6
Year:
Make:
Model:
VIN Number:
Primary Use: (Commute, Pleasure, Business, ect.):
Estimated Annual Mileage:
Driver(s) of this vehicle:
Lienholder:
Additional Driver Information 1
Full Name:
Relation to Primary: (Spouse, Child, Not Related, etc.):
Date of Birth:
Driver's License Number:
State of Issue:
Accident/Violations in the past 3 years?
Additional Driver Information 2
Full Name:
Relation to Primary: (Spouse, Child, Not Related, etc.):
Date of Birth:
Driver's License Number:
State of Issue:
Accident/Violations in the past 3 years?
Additional Driver Information 3
Full Name:
Relation to Primary: (Spouse, Child, Not Related, etc.):
Date of Birth:
Driver's License Number:
State of Issue:
Accident/Violations in the past 3 years?
Additional Driver Information 4
Full Name:
Relation to Primary: (Spouse, Child, Not Related, etc.):
Date of Birth:
Driver's License Number:
State of Issue:
Accident/Violations in the past 3 years?
Recreational Vehicle Insurance

Please Provide the following information for each recreational vehicle: (e.g., Motorhome, Travel Trailer, Motorcycle, ATV, Boat, Snowmobile, etc.)
Motorhome/Travel Trailer:
Type: (5th Wheel, Conventional, RV- CLASS A,B,C):
Year:
Make:
Model:
VIN:
Number of Slide Outs:
Purchase Prince/Value:
Primary Use: (Commute, Pleasure, Business, etc.):
Storage Location: (If different from home address):
Lienholder:
Boat:
Year:
Make:
Model:
VIN/Hull ID:
Lienholder:
Trailer Included:
(yes/no):
Year:
Make:
Model:
VIN:
Purchase Price/Value:
Motor:
Year:
Make:
Model:
VIN:
Horse Power/Max Speed:
Purchase Price/Value:
Primary Use:
Storage Location: (If different from home address):
ATV/UTV:
Type of RV:
Year:
Make:
Model:
VIN:
Purchase Price/Value:
Primary Use: (On road, Off Road):   Storage Location: (If different from home address):
Lienholder:
Motorcycle:
Year:
Make:
Model:
VIN:
Purchase Price/Value:
Primary Use: (Commute, Pleasure, Business, etc.):
Off Road Use: (yes/no):
Storage Location: (If different from home address):
Lienholder:
Additional Recreational Vehicle(s) 1
Type of RV:
Year:
Make:
Model:
VIN/Hull ID:
Purchase Price/Value:
Primary Use: (Commute, Pleasure, Business, etc.):
Off Road Use: (yes/no):
Storage Location: (If different from home address):
Lienholder:
Additional Recreational Vehicle(s) 2
Type of RV:
Year:
Make:
Model:
VIN/Hull ID:
Purchase Price/Value:
Primary Use: (Commute, Pleasure, Business, etc.):
Off Road Use: (yes/no):
Storage Location: (If different from home address):
Lienholder:
Additional Recreational Vehicle(s) 3
Type of RV:
Year:
Make:
Model:
VIN/Hull ID:
Purchase Price/Value:
Primary Use: (Commute, Pleasure, Business, etc.):
Off Road Use: (yes/no):
Storage Location: (If different from home address):
Lienholder:
Additional Recreational Vehicle(s) 4
Type of RV:
Year:
Make:
Model:
VIN/Hull ID:
Purchase Price/Value:
Primary Use: (Commute, Pleasure, Business, etc.):
Off Road Use: (yes/no):
Storage Location: (If different from home address):
Lienholder:
Additional Recreational Vehicle(s) 5
Type of RV:
Year:
Make:
Model:
VIN/Hull ID:
Purchase Price/Value:
Primary Use: (Commute, Pleasure, Business, etc.):
Off Road Use: (yes/no):
Storage Location: (If different from home address):
Lienholder:
Additional Recreational Vehicle(s) 6
Type of RV:
Year:
Make:
Model:
VIN/Hull ID:
Purchase Price/Value:
Primary Use: (Commute, Pleasure, Business, etc.):
Off Road Use: (yes/no):
Storage Location: (If different from home address):
Lienholder:
Additional Recreational Vehicle(s) 7
Type of RV:
Year:
Make:
Model:
VIN/Hull ID:
Purchase Price/Value:
Primary Use: (Commute, Pleasure, Business, etc.):
Off Road Use: (yes/no):
Storage Location: (If different from home address):
Lienholder:
Additional Recreational Vehicle(s) 8
Type of RV:
Year:
Make:
Model:
VIN/Hull ID:
Purchase Price/Value:
Primary Use: (Commute, Pleasure, Business, etc.):
Off Road Use: (yes/no):
Storage Location: (If different from home address):
Lienholder:
Additional Recreational Vehicle(s) 9
Type of RV:
Year:
Make:
Model:
VIN/Hull ID:
Purchase Price/Value:
Primary Use: (Commute, Pleasure, Business, etc.):
Off Road Use: (yes/no):
Storage Location: (If different from home address):
Lienholder:
Additional Recreational Vehicle(s) 10
Type of RV:
Year:
Make:
Model:
VIN/Hull ID:
Purchase Price/Value:
Primary Use: (Commute, Pleasure, Business, etc.):
Off Road Use: (yes/no):
Storage Location: (If different from home address):
Lienholder:
Contact Preferences
Preferred Method of Contact:

PhoneEmailText
Best Time to Contact You:
Will you be willing to recommend us?

YesNoMaybe
Aurora Insurance Solutions LLC
Privacy Policy

Effective Date: 01/24/2025

1. Information We Collect
When you complete our intake form, we collect personal information that may include:
Full name, address, email, and phone number etc.
Driver’s license number.
Social security number.
Date of birth and marital status.
Insurance history and claims details.
Property and vehicle details.
Business information (if applicable).
We collect this information solely for the purpose of providing insurance quotes, risk assessments, and related services.

2. How We Use Your Information
We use the information you provide to:
Evaluate and quote insurance coverage.
Contact you regarding your inquiry or policy.
Comply with regulatory or underwriting requirements.
Maintain internal business records as required by law.
We do not sell, rent, or trade your personal information to third parties.

3. Sharing Your Information
We may share your data only with:
Licensed insurance carriers and underwriters for quoting and policy issuance.
Third-party service providers who help us deliver our services (e.g., CRMs, quoting tools)
Government or legal authorities if required by law or in response to legal process.
All third parties are required to protect your information in accordance with applicable privacy laws.

4. Data Security
We take reasonable administrative, technical, and physical safeguards to protect your personal information from unauthorized access, disclosure, or misuse.

5. Your Consent
By submitting this form, you:
Consent to the collection and use of your information as outlined in this policy.
Agree to receive phone calls and text messages from Aurora Insurance Solutions LLC at the number you provide.
Understand that these communications may include marketing content, appointment reminders, and policy updates.
Acknowledge that message and data rates may apply, and that you may opt out at any time by replying "STOP" or contacting us directly.

6. Your Rights
You may request access to, correction of, or deletion of your personal information at any time by contacting us at:

7. Updates to This Policy
We reserve the right to update this policy at any time. Changes will be posted on our website or communicated via email when appropriate.

8. Contact Us
For questions about this privacy policy, please contact:

Kai Marder
Aurora Insurance Solutions LLC
Email: Kai.M@AuroraInsuranceSolutionsLLC.com
Call/Text: (330) 486-8133

Remote office located in Twinsburg, OH
Should be Empty:

New Client Intake Form

Home/ Renters Insurance

Auto Insurance

Recreational Vehicle Insurance

Contact Preferences