Home Insurance Intake Form
Starkey Insurance Group
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Marital Status
Single
Married
Divorced
Widowed
Preferred Contact Method
Phone
Text
Email
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Prior Insurance Information
Name of Carrier
Policy Expiration Date
-
Month
-
Day
Year
Date
How much are you currently paying for home insurance each month?
What is the desired amount of coverage for your home?
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Property Details
Section 2
Property Address (If different from the personal/home address listed above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Year Purchased
-
Month
-
Day
Year
Date
Year Built
-
Month
-
Day
Year
Date
Number of occupants in the property
Number of Stories
Square Footage
Heating System Type
Year heating system was installed or most recently replaced
-
Month
-
Day
Year
Date
Is there any supplemental heating in the property? If yes, please specify the type and location.
Year plumbing system was installed or last updated
-
Month
-
Day
Year
Date
Year electrical system was installed or last updated
-
Month
-
Day
Year
Date
Roof Type & Year Last Replaced
Foundation Type
Slab
Crawl Space
Basement
Other
If the property has a basement, what percentage of it is finished?
Exterior Construction Type (e.g., brick, vinyl siding, etc.)
Number of Bathrooms
Garage Type
Attached
Detached
None
If the property has an attached garage, how many vehicles can it accommodate?
Are there any detached structures on the property (e.g., shed, pole barn, chicken coop, etc.)? If yes, please specify the type and estimated square footage of each.
Is there a porch or deck attached to the property?
Yes
No
Do you have animals?
Yes
No
If yes, List the Breed(s) and Number of Pets or Farm Animals
Does the property have a swimming pool/trampoline?
Yes
No
If yes, Is it:
Fenced
Gated
Netted
Other
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Schedule an appointment for your free home insurance quote consultation. Choose a date that works for you!
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