ACTIVE Home and Auto Insurance Quote Form

Page Insurance, Ltd

102 Boston Street

Guilford, CT 06437

(203) 453-5258

info@pageins.com
Effective / Closing Date

MonthDayYear
Today's Date

MonthDayYear
Where did you hear about Page Insurance?
Questions with * can be obtained elsewhere
TYPES OF INSURANCE REQUESTED

HomeownersRentersAutoRented DwellingVacantUmbrella
Name of Building Owner if other than individual
Name

First NameLast Name
DOB

MonthDayYear
Occupation
Marital Status
Other Named Insured?

YesNo
Spouse / Other Named Insured

First NameLast Name
Spouse / Other DOB

MonthDayYear
Occupation
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
E-mail
Cell Phone Number

Area CodePhone Number
What is the best day/time to get in touch with you?
Best Method to Contact

PhoneEmailEither
Current Company
Location Address is the same as the mailing address
Location Address

Street Address

Street Address Line 2

CityState

Zip Code
Do you have city water?

YesNo
Is the house within 1,000 feet of a fire hydrant?

YesNo
Protection Class (if known)
FOR UNDERWRITING USE
Build Quality

AverageSemi-CustomCustom

Quote Requirements

	Yes	No
Replacement Cost Calculated?
Assessors Field Card
Canceled/Non-Renewed/Declined Past (3) years?
Claims in the past (3) years?
Continuous Coverage for Past Year

If Yes, Explain:
CURRENT / PROPOSED POLICY LIMITS
Dwelling Limit
Other Structures
Personal Property
Loss of Use
Liability Limit
Medical Payments
Number of Families

12345More than 5
Do you have any dogs?

YesNoOther
Other Animals / Pets

YesNoOther
Do you have a wood stove?

YesNo

Swimming Pool

YesNo
Above or In-ground?

Above GroundIn Ground

Fence/DB/Slide?

	Yes	No
Fenced
Diving Board
Slide

Do you have any of the following?

	Yes	No
Do you have a trampoline?
If yes, does it have a net around it?
Do you have an underground Oil tank?
Do you rent to college students?
Do you conduct any business In the home?

Type of In-Home Business
Average # of Clients Daily

Do you have an alarm system?

	Yes	No
CS Burglar
CS Fire
Local Smoke
Deadbolts
Fire Extinguishers

BUILDING AND UPDATE INFORMATION
Year Built*
Square Feet*
Construction Quality

Builders GradeSemi-CustomCustom
Is the basement finished?

YesNoN/A
What percentage of the basement is finsihed?
Roof Updates

YesNoOriginalUnknown
Year
PartialComplete
Plan to replace roof?

YesNo
If yes, when?
Electrical Updates

YesNoOriginalUnknown
Year
PartialComplete
# Amps

60100200

Circuit Protection

	Yes	No
Circuit Breakers
Any fuses?
Knob/Tube Wiring

Plumbing Updates

YesNoOriginalUnknown
Year
Heating Updates

YesNoOriginalUnknown
Year
Type of Heat

OilGasElectricPropane
Type of updates
Location of Oil Tank:
Last Service Date

MonthDayYear
Do you have a mortgage?*

YesNo
Mortgagee Information
Contact Information @ Bank
If New Purchase, do they require payment in full for the first year?

YesNo
Who will be billed on renewal?

BankInsured
Personal Auto Insurance Quote Form
Are you interested in a Personal Auto Insurance Quote?

YesNo
Driver Information
Vehicle Information*Usage = Pleasure (P) Commute (C)
Coverages
Personal Umbrella Liability Quote Form
Are you interested in a Personal Umbrella Policy?

YesNo
Limit
# of Homes
# Rental Homes
# of Vehicles
Number of Youthful Operators
TOTAL Premium
Other Location #1
Other Location #2
Other Location #3
NOTES
CLIENT INFORMATION Entered in IntellectQUOTE Task Created in IntellectCreate Folder in Scanned docs
Once policy has been sold obtain following Documentation:

Signed Application, quote, payment etc.Signed Cancellation if applicableSigned Flood Selection / Rejection letter or Quote requestSigned Personal Umbrella Quote Selection / Rejection Form
Amend task to Priority "Inbox" assign to ASTRID
Set up policy in Prime
Create contact in PrimeCreate policy (including the A-Trans)Attach the following document in order: (Most documents can be found in insured folder Scanned docs)--- Information sheet--- property card--- replacement cost calculation--- application(s)--- quote(s)--- Signed application--- Bind request if applicableCopy notes all from intellect to Prime.Delete folder from scanned docs
Amend task to Priority "Inbox" assign to @ Daily
ADD TO ENEWS Task create in Intellect (Priority B, Assign @daily)SEND THANK YOU NOTE task create in intellect (Priority B, Assign @daily)
Amend task to Priority "NEW BUSINESS" assign to Pending new business
Should be Empty:

	Yes	No
Prof Install
Inspected?
Cleaned Annually

FOR UNDERWRITING USE