Intake Form (Personal Lines) Step 1 of 20 5% Primary Insured InfoName(Required) First Last PhoneEmail MonthPlease enter a number from 1 to 12.DayPlease enter a number from 1 to 31.YearPlease enter a number from 1910 to 2050.Drivers LicenseSSNOccupationHighest Level of Education completed for primary insured.High SchoolCommunity CollegeBachelorsMastersDoctorateMarital StatusSingleMarriedDivorcedWidowedReferred By Name First Last Insurance Advisor(Required)Dane WilliamsCary ChestonJonathan JewellSpouse InformationSpouse's Name First Last Spouse DOBMonthSpouse DOBYearSpouse DOBDaySpouse PhoneSpouse Email Spouse OccupationHighest Level of Education completed for spouse.High SchoolCommunity CollegeBachelorsMastersDoctorateExpiration Date of PolicyWhat company are you currently with?MonthPlease enter a number from 1 to 12.DayPlease enter a number from 1 to 31.YearPlease enter a number from 1910 to 2050.Policy Term 6 Months 12 Months Annual Premium?What type of insurance can we quote for you? Auto Home Condo Umbrella Investment Property Motorcycle/Slingshot/ATV Golf Cart Boat RV Renter's Policy Other What other type of insurance can we quote for you?New purchase or already own the condo/home? New Purchase Already Own How do you use the condo? Primary Residence Secondary Residence Rental Current Address (No PO Boxes) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this the address you are (or will be) renting? Yes No Rental Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Personal Property LimitPlease enter a number greater than or equal to 20000.Address of Property Being Purchased Same as current address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Purchase Date / Anticipated Purchase DateMonthPlease enter a number from 1 to 12.DayPlease enter a number from 1 to 31.YearPlease enter a number from 1910 to 2050.Would you like to add a different mailing address? Yes No Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of Adults in the home - Ages of AdultsNumber of Kids in the home - Ages of kidsYear Home Was BuiltPlease enter a number from 1800 to 2050.Sq FtBedrooms 1 2 3 4 5 # of stories 1 1.5 2 3 4 Bathrooms11.522.533.544.5Garage None Attached 1 Car Attached 2 Car Attached 3 Car Attached 4 Car Built-In 1 Car Built-In 2 Car Built-In 3 Car Built-In 4 Car Carport - 1 Car Carport - 2 Car Carport - 3 Car Carport - 4 Car Detached - 1 Car Detached - 2 Car Detached - 3 Car Detached - 4 Car Additional Structures Yes No Additional Structure DescriptionMore than 5 acres? Yes No How many?Fireplace Yes No Swimming Pool Yes No Type of Pool Above Ground In Ground Size of PoolSwimming Pool Enclosed/Fenced? Yes No Diving Board or Slide? Diving Board Slide Neither Gated Community? Yes, Passkey Gate Entrance Yes, 24 Hour Manned Gate None Monitored Burglar/Fire Alarm? Yes No Sprinklers Yes No Central or Local Larm?CentralLocalSolar Panels Yes No How Many Solar Panels? Add RemoveDog(s)? Yes No Any bite history or Security Training?Dog Breeds Add RemoveIf mixed please indicate type of mix.Are you aware of any previous settlement or sinkhole issues on the property? Yes No Have you had any home or renter's insurance claims in the past 5 years? Yes No What was the claim? - Amount - Date Home DetailsExterior MaterialBrick VeneerClapboardVinyl SidingStone VeneerStuccoRoof MaterialComposite ShinglesAsphalt ShinglesArchitectural ShinglesMetalTileYear Roof UpdatedYear Electrical UpdatedYear Plumbing Updated?Year HVAC UpdatedDwellingLoss of UseWind/Hail DeductibleAll Other Perils DeductibleOther StructuresPersonal PropertyLiability $100,000 $300,000 $500,000 Medical Payments $5,000 Second Choice Third Choice Lending Institution / ContactRealtor (If New Purchase)Closing DateMonthPlease enter a number from 1 to 12.DayPlease enter a number from 1 to 31.YearPlease enter a number from 1910 to 2050.Loan AmountScheduled Personal Property Artwork Collectibles Firearms Jewelry Technology Other Valuable Items List (Click the + to add additional items) Add RemovePlease list each item and include an appraised/estimated value. Only one item per row please.Home Notes DL#DL StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificUNKNOWN WILL FOLLOW UPTotal Drivers in Home 1 2 3 4 5 Total Vehicles in Home 1 2 3 4 5 Current Liability Limits $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 $300,000 CSL $500,000 CSL Other UM/UIM $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 $300,000 CSL $500,000 CSL Rejected UM Comprehensive Deductible Decline Comp $100 $250 $500 $1,000 Collision Deductible Decline Collision $100 $250 $500 $1,000 Rental Reimbursement Yes No Other Rental Reimbursement $30/Day $50/Day Roadside Assistance Yes No Student Good Student Student Away at School Drivers Ed Course None Vehicle #1MakeModelVehicle YearVINBusiness Use Yes No Rideshare or Delivery? Yes No Driver #2Name First Last PhoneEmailDate of BirthMonthPlease enter a number from 1 to 12.DayPlease enter a number from 1 to 31.YearPlease enter a number from 1910 to 2050.DL#DL StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificUNKNOWN WILL FOLLOW UPOccupationRelationship to primary insured Spouse Child Parent Other Self Vehicle #2Vehicle YearVehicle MakeVehicle ModelVINBusiness Use Yes No Explain what Business UseRideshare or Delivery Yes No Rental Reimbursement $30/Day $50/Day Rental Reimbursement Yes No Other Collision Deductible Decline Collision $100 $250 $500 $1,000 Comprehensive Deductible Decline Comp $100 $250 $500 $1,000 Driver #3Name First Last PhoneEmail Date of BirthMonthPlease enter a number from 1 to 12.DayPlease enter a number from 1 to 31.YearPlease enter a number from 1910 to 2050.DL#DL StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificUNKNOWN WILL FOLLOW UPOccupationRelationship to primary insured Spouse Child Parent Other Vehicle #3Vehicle YearVehicle MakeVehicle ModelVINBusiness Use Yes No Explain what Business UseRideshare or Delivery Yes No Rental Reimbursement Yes No Other Rental Reimbursement $30/Day $50/Day Comprehensive Deductible Decline Comp $100 $250 $500 $1,000 Collision Deductible Decline Collision $100 $250 $500 $1,000 Driver # 4Name First Last PhoneEmail Date of BirthMonthPlease enter a number from 1 to 12.DayPlease enter a number from 1 to 31.YearPlease enter a number from 1910 to 2050.DL#DL StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificUNKOWN WILL FOLLOW UPOccupationRelationship to primary insured Spouse Child Parent Other Vehicle #4Vehicle YearVehicle MakeVehicle ModelVINBusiness Use Yes No Explain what Business UseRideshare or Delivery Yes No Rental Reimbursement Yes No Other Rental Reimbursement $30/Day $50/Day Comprehensive Deductible Decline Comp $100 $250 $500 $1,000 Collision Deductible Decline Collision $100 $250 $500 $1,000 Driver #5Name First Last PhoneEmail Date of BirthMonthPlease enter a number from 1 to 12.DayPlease enter a number from 1 to 31.YearPlease enter a number from 1910 to 2050.DL#DL StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificUNKNOWN WILL FOLLOW UPOccupationRelationship to primary insured Spouse Child Parent Other Vehicle #5Vehicle YearVehicle MakeVehicle ModelVINBusiness Use Yes No Explain what Business UseRideshare or Delivery Yes No Rental Reimbursement Yes No Other Rental Reimbursement $30/Day $50/Day Comprehensive Deductible No Comp $100 $250 $500 $1,000 Collision Deductible No Collision $100 $250 $500 $1,000 Investment PropertyAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Square FeetYear BuiltAcresSwimming PoolYesNoDiving Board or SlideDiving BoardSlideNeitherBothFire Alarm - Alarm System Fire Alarm Alarm System Both Neither Property Status Currently Occupied with Tenants Listed For Sale - No Occupants Listed For Rent - No Occupants Undergoing Renovations - Vacant Motorcycle/Slingshot/ATVName of Primary Driver First Last Vehicle Type Motorcycle Slingshot ATV Is Vehicle Used for Racing? Yes No Current Motorcycle License Yes No Has Driver Completed Safety Course? Yes No YearMakeModelVIN UmbrellaIn order to purchase an umbrella liability policy you must have auto liability limits of at least $250,000/$500,000/$250,000 and home/renters liability of at least $300,000. I understand that if the current liability limits on my auto and home/renters policies do not meet those minimums I will not be eligible to purchase an umbrella liability policy. How many homes do you own?This includes primary, secondary, vacation, rental and investment properties.How many home/renters claims have you made in the last 5 years?How many vehicles do you own?How many auto claims have you made in the last 5 years?Any drivers on your auto policy have an at-fault accident in the last 5 years? Yes No Do you own any of the following items? Boat/Yacht Motorcycle ATV Golf Cart Vacant Land Business None Boat InformationWhere is boat stored? Primary Residence Marina - Slip Marina - Dry Stack Other YearMakeModelHull NumberMotor Type Inboard Outboard Top Speed (MPH)Boat LengthBoat is used for racing? Yes No Do you own a boat trailer? Yes No Golf CartYearMakeModelPrimary Use Transportation Golfing Fuel Type Electric Gas Recreational VehicleRV Type 5th Wheel Motorcoach Other Years of Operating Use1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465666768697048Do you drive to and from work location?YesNoStationary Option?First Owner?Market ValueHow many days per year of use?123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300301302303304305306307308309310311312313314315316317318319320321322323324325326327328329330331332333334335336337338339340341342343344345346347348349350351352353354355356357358359360361362363364365Length (Feet)123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100YearMakeModel Please upload current policy documents if you have them available.Max. file size: 5 MB.