Personal Lines Intake Form
Please fill the form accurately for better assistance
How did you hear about us? Were you referred by anyone?
*
Please Select
Website
google
Referral
What is the name of the person who referred you? We would like to send them a quick thank you.
Lines of business to be quoted:
*
Home
Condo
Renters
Auto
Umbrella
Valuable Articles
Rec Vehicle / Motorcycle
Boat
Motorhome
Other
When do you need this quote returned by?
*
-
Month
-
Day
Year
Date
Customer Info
Primary Insured Name
*
First Name
Last Name
Primary Insured Date of Birth:
*
-
Month
-
Day
Year
Date
Relationship Status
*
Married
Single
Widowed
Divorced
Other
Spouse Name
*
First Name
Last Name
Spouse Date of Birth:
*
-
Month
-
Day
Year
Date
Primary E-mail
*
example@example.com
Primary Insured Cell
*
Customer gave permission to text this number:
*
Yes
No
Primary Insured Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you been at this address?
Please Select
1year
2year
3-5 years
5+ years
Is current insurance active?
*
Yes
No
Other
Name of Current Carrier
Current Premium to Beat:
When does your current insurance expire?
*
-
Month
-
Day
Year
Date
Umbrella Coverage
Limit Requested
*
Please Select
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Do you want UM/UIM coverage?
*
Yes
No
Any international travel planned?
*
Yes
No
Valuable Articles
Valuable Articles List
*
Amount
Description
Appraisal Attached
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Desired Ded.
*
Attach Appraisal(s)
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Watercraft
Watercraft Info
*
Year / Make / Model
Hull Number
Motor Yr/Make
Max Speed
HP or CC
Trailer amount
Watercraft 1
Watercraft 2
Watercraft 3
Watercraft 4
Rec Vehicle / Motorcycle
Rec Vehicle / Motorcycle Driver Info
*
Name / Relationship
DOB
Drivers License
Social
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5
Driver 6
Rec Vehicle / Motorcycle Info
*
Year/Make/Model
Serial Number
Value
CC / HP
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Rec Vehicle / Motorcycle Liability Limits
*
Limits Requested
Liability Limits - Suggested 250/500
Property Damage - Suggested 100
Medical - $10,000
UM - Suggested 250/500
UIM - Suggested 250/500
Comp Ded - Suggested $1,000
Coll Ded - Suggested $1,000
Other Not Listed - Document Coverage needed
Do any of the Rec Vehicle / Motorcycle have a loan or lease
*
Yes
No
List the vehicle number - Name / Address - Loan or Reference Number
Auto Questions
Auto Driver Info
*
Name / Relationship
DOB
Drivers License
Social
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5
Driver 6
Vehicle Info
*
Year/Make/Model
Vin
Deductible
Usage
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Do any of the Vehicles have a loan or lease
*
Yes
No
List the vehicle number - Name / Address - Loan or Reference Number
Ticket or Accidents last 3 years?
*
Yes
No
List any tickets or accidents in the last 3 years:
Do you use any of these vehicles in the course of business?
*
Yes
No
List Vehicle Number - How is this vehicle used in the course of business?
Preferred Vehicle Liability Limits
*
Limits Requested
Liability Limits - Suggested 250/500
Property Damage - Suggested 100
Road Side - Included, can remove after review
Medical - $10,000
UM - Suggested 250/500
UIM - Suggested 250/500
Comp Ded - Suggested $1,000
Glass - Included, can remove after review
Coll Ded - Suggested $1,000
Telematics - Included, can remove after review
OEM Coverage -
Other Not Listed - Document Coverage needed
Available discounts discussed with prospect
Good Student
Low Milage
Occupation Discount
Other
Supporting discount documents:
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Condo Quote
Coverage Options
*
Limits Requested
Personal Property Coverage
Structure Coverage
Water/Sewer - Included, $25,000
Personal Injury - Included, can remove after review
ID Theft - Included, can remove after review
Policy Deductible
Loss Assessment Coverage Amount
Renters Questions
Coverage Options
*
Limits Requested
Personal Property Coverage
Water/Sewer - Included, $25,000
Personal Injury - Included, can remove after review
ID Theft - Included, can remove after review
Policy Deductible
Home Questions
Home details
*
Home Details
Year Built
Construction Type (Brick, Frame, Stucco...)
Roof Material
Total square footage (excluding basement)
# of Stories
# of Bathrooms
Foundation Type & Percent Finished
Garage (# of Bays / Attached or Detached)
Trampoline or Pool & is it fenced
Fireplace or Chimney
Anything Attached to the home (deck, porch...)
Link to this home on the assessors site:
*
Type NA if not available
Updates to property
*
Limits Requested
Roof year
Plumbing Year & Full or Partial
Electrical Year & Full or Partial
HVAC Year & Full or Partial
Coverage Options
*
Limits Requested
Earthquake
Water/Sewer - Included, $25,000
Personal Injury - Included, can remove after review
ID Theft - Included, can remove after review
Flood
Mine Subsidence/Sink Hole
Work Comp
Valuable Articles - Included, can remove after review
Service Line Coverage
Sinkhole Coverage
Dog or Exotic Pet on premise
*
Yes
No
Any known bite history?
*
Yes
No
Provide pet details here, breed or type of pet:
*
If unknown please use customers best guess
Are you aware of any claims in the last 3 years?
*
Yes
No
List claims details below:
Is their a mortgage on the home?
*
Yes
No
Name of Bank or Institution - Address - Loan #
Is this home in a Trust or LLC?
*
Yes
No
List the Trust or LLC as it should be listed (*Carrier may request copies of titles if you have them attached at bottom of submission)
Attachments & Notes
Attachments to save to the account:
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Notes on the account:
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Should be Empty: