Personal Lines Intake Form

How did you hear about us? Were you referred by anyone? *

What is the name of the person who referred you? We would like to send them a quick thank you.

Who is the agent to be assigned to this account? *

What is the email of person who should receive a copy of the completed form?*

When do you need this quote returned by? *

Date

Primary Insured Name*

First NameLast Name

Primary Insured Date of Birth: *

Date

Spouse Name*

First NameLast Name

Spouse Date of Birth: *

Date

Primary E-mail*

example@example.com

Primary Insured Cell*

Format: (000) 000-0000.

YesNo

Primary Insured Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How long have you been at this address?

YesNoOther

Name of Current Carrier

Current Premium to Beat:

When does your current insurance expire? *

Date

YesNo

Agent/CSR appointment setting process

1. Use the Following Info to complete the scheduling link

Customer Name: {primaryInsured}
Call Back Number: {phoneNumber40}
Quotes Requested: {linesOf}

2. Use Agent Scheduling Link Below

Bill Kaatman
Agent Name 2 (Calendly Link)
Agent Name 3 (Calendly Link)
- Free Calendly Account: Click Here

Limit Requested*

YesNo

Valuable Articles List*

Rows	Amount	Description	Appraisal Attached
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6

Desired Ded. *

Attach Appraisal(s)

Watercraft Info*

Rows	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 Driver Info*

Rows	Name / Relationship	DOB	Drivers License	Social
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5
Driver 6

Rec Vehicle / Motorcycle Info*

Rows	Year/Make/Model	Serial Number	Value	CC / HP
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5

Rec Vehicle / Motorcycle Liability Limits*

Rows	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

YesNo

List the vehicle number - Name / Address - Loan or Reference Number

Auto Driver Info*

Rows	Name / Relationship	DOB	Drivers License	Social
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5
Driver 6

Vehicle Info*

Rows	Year/Make/Model	Vin	Deductible	Usage
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5

YesNo

List the vehicle number - Name / Address - Loan or Reference Number

YesNo

List any tickets or accidents in the last 3 years:

YesNo

List Vehicle Number - How is this vehicle used in the course of business?

Preferred Vehicle Liability Limits*

Rows	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

Good StudentLow MilageOccupation DiscountOther

Supporting discount documents:

Coverage Options*

Rows	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

Coverage Options*

Rows	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 details*

Rows	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*

Rows	Limits Requested
Roof year
Plumbing Year & Full or Partial
Electrical Year & Full or Partial
HVAC Year & Full or Partial

Coverage Options*

Rows	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

YesNo

Provide pet details here, breed or type of pet: *

If unknown please use customers best guess

YesNo

List claims details below:

YesNo

Name of Bank or Institution - Address - Loan #

YesNo

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 to save to the account:

Notes on the account:

Personal Lines Intake Form

Customer Info

Umbrella Coverage

Valuable Articles

Watercraft

Rec Vehicle / Motorcycle

Auto Questions

Condo Quote

Renters Questions

Home Questions

Attachments & Notes