Client Information Sheet
Please fill out all fields marked with an *asterisk*
Primary Insured Name
*
First Name
Last Name
Primary Insured Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Insured Occupation
Affinity Discounts (ie: Teacher, Lawyer, Realtor, Law Enforcement, etc)
Spouse Name
First Name
Last Name
Spouse Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Insured Phone
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How Did You Hear About Us
Ie: Google, Yelp, Social Media, Referral, etc.
Current Auto Insurance
Carrier
Requested Insurance Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Vehicle 1 Info
Year, Make, Model and VIN
Vehicle 1 Odometer
Current Mileage
Vehicle 2 Info
Year, Make, Model and VIN
Vehicle 2 Odometer
Current Mileage
Policy Limits
25/50/25
50/100/50
100/300/100
250/500/250
Current Liability Limits
Deductible
250
500
1000
1500
Current Deductible for Comp/Collision
Endorsements
Towing/Roadside Assistance
Rental Car
Glass Coverage
OEM (original manufacturer parts)
Youthful Drivers
Name and DOB
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Homeowners Insurance
Current Carrier
Current Annual Premium
Year Built
Square Feet
Loan Amount
Number of Stories
Number of Bedrooms/Bathrooms
Ex: 3/1.5
Foundation
Slab
Crawlspace
Pier & Beam
Roof Material
Architectural Shingle
3 Tab Shingle
Tile
Cement Fiber
Exterior
Stucco, Brick, Wood siding, etc.
Home Updates
Roof
Heating/AC
Electrical
Plumbing
Other
Year of Updates, if Checked
Ex: Roof 2000, HVAC 2005, Kitchen 2017,
Current Declaration Pages
Browse Files
Cancel
of
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Life Insurance
Do you have Life Insurance through a group plan?
Yes
No
Current Life Insurance Amount
Zero
$50,000 - $100,000
$100,000 - $250,000
$250,000 - $500,000
$500,000 - $1,000,000
$1,000,000+
Coverage Amount Needed
Ex: $150,000
Tobacco Use
Yes
No
Height
feet & inches
Weight
pounds
List Medical Issues, Surgeries or Medications
Ie: Heart Attack 05/2008, diabetes, appendix removal 5/1997
If you do NOT want life insurance, please initial in the box below:
*
Ex: AJ
Submit
Should be Empty: