Campbell * Personal Intake Form * (1) Step 1 of 13 7% What type of insurance can we quote for you? Click all that apply.(Required) Auto Home/Townhome Condo Builders Risk (Coverage During Construction) Umbrella Motorcycle/Slingshot/ATV Golf Cart Boat RV Renters New purchase or already own the property?(Required) New Purchase Already Own Is the property currently insured?(Required) Yes – I have maintained my coverage. No – I have lapsed (Less than 30 Days) No – I have lapsed (More than 30 Days) Maybe – My lender force placed insurance How is / will the property be occupied? CLICK ALL THAT APPLY(Required) Primary Residence Secondary Residence Rented What is the SHORTEST amount of time it will be rented?(Required) Annual Rental (Monthly Payments) Monthly Rental (Short-Term) Weekly Rental (Short-Term) Nightly Rental (Short-Term) When will the property be occupied by owner or tenant?(Required) 0-15 days after closing? 16-30 days after closing? 30+ Days after closing? Plans for the property over the next 12 months.(Required)Select OptionContinue to Live In (If already own)Move InRenovate then Move InRentRenovate then RentPlease describe the types of renovations planned:(Required) How is / will the property be titled?(Required) Personal Name(s) Trust LLC Corporation In Probate Entity Name of: Trust, LLC, Corp or Probate (if applicable) Name(Required) First Last Mobile Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Driver's License(Required) Highest Level of Education(Required) Highschool Diploma / GED Some College Associate Degree Bachelor’s Degree Masters / Doctorate / Law Degree Occupation(Required) Is there another person who will have an insurable interest in the property / vehicle being insured?(Required) Yes No Co-Applicant Name(Required) First Last Co-Applicant Mobile Phone (Must be different from Applicant)(Required)Co-Applicant Email (Must be different from Applicant)(Required) Co-Applicant Date of Birth(Required) MM slash DD slash YYYY Driver's License(Required) Co-Applicant Occupation(Required) Highest Level of Education(Required) Highschool Diploma / GED Some College Associate Degree Bachelor’s Degree Masters / Doctorate / Law Degree Referred By(Required) Realtor Lender You are a Current Client Friend / Family Nextdoor Facebook School (County) Discount Page Internet So that we can thank the person who referred you, can you tell us their name?(Required) Which County School System?(Required) Who is the primary point of contact?(Required) Current Address (No PO Boxes)(Required) 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 Address of Property Being Purchased(Required) 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 Would you like to add a different mailing address?(Required) Yes No Mailing Address(Required) 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 the home in a Gated Community?(Required) Yes, Passkey Gate Entrance Yes, 24 Hour Manned Gate No Do you or will you have a Monitored Burglar/Fire Alarm?(Required) Yes No Are there any Dog(s) on Property?(Required) Yes No Dog Breeds(Required) Add RemoveIf mixed please indicate type of mix.Any bite history or security training?(Required) Yes No Do you have or will you have a Trampoline on the Property?(Required) Yes No Are you aware of any previous settlement or sinkhole issues on the property?(Required) Yes No Have you had OR reported any home or renter's insurance claims in the past 5 years?(Required) Yes No Approximate Date of Loss(Required) MM slash DD slash YYYY Approximate Amount(Required)Please describe the loss as best you can remember.(Required) Please add any additional notes that you think we should know: Auto InformationTotal Drivers in Home(Required)12345Total Vehicles in Home(Required)12345Driver #2Name(Required) First Last Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Driver's License(Required) Occupation(Required) Relationship to Primary Applicant(Required) Spouse Child Parent Other Does this driver have a primary vehicle?(Required) Yes No Driver #3Name(Required) First Last Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Driver's License(Required) Occupation(Required) Relationship to Primary Applicant(Required) Spouse Child Parent Other Does this driver have a primary vehicle?(Required) Yes No Driver #4Name(Required) First Last Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Driver's License(Required) Occupation(Required) Relationship to Primary Applicant(Required) Spouse Child Parent Other Does this driver have a primary vehicle?(Required) Yes No Driver #5Name(Required) First Last Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Driver's License(Required) Occupation(Required) Relationship to Primary Applicant(Required) Spouse Child Parent Other Does this driver have a primary vehicle?(Required) Yes No Vehicle #1VIN Vehicle Year(Required) Make(Required) Model(Required) Business Use(Required) Yes No Type of Business(Required) Rideshare or Delivery?(Required) Yes No Vehicle #2VIN Vehicle Year(Required) Vehicle Make(Required) Vehicle Model(Required) Business Use(Required) Yes No Type of Business(Required) Rideshare or Delivery(Required) Yes No Vehicle #3VIN Vehicle Year(Required) Vehicle Make(Required) Vehicle Model(Required) Business Use(Required) Yes No Type of Business(Required) Rideshare or Delivery(Required) Yes No Vehicle #4VIN Vehicle Year(Required) Vehicle Make(Required) Vehicle Model(Required) Business Use(Required) Yes No Type of Business(Required) Rideshare or Delivery(Required) Yes No Vehicle #5VIN Vehicle Year(Required) Vehicle Make(Required) Vehicle Model(Required) Business Use(Required) Yes No Type of Business(Required) Rideshare or Delivery(Required) Yes No Investment PropertyAddress(Required) 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 Property Status(Required) Currently Occupied with Tenants Listed For Sale – No Occupants Listed For Rent – No Occupants Undergoing Renovations – Vacant Motorcycle/Slingshot/ATVName of Primary Driver(Required) First Last Vehicle Type(Required) Motorcycle Slingshot ATV Is Vehicle Used for Racing?(Required) Yes No Current Motorcycle License(Required) Yes No Has Driver Completed Safety Course?(Required) Yes No Year(Required) Make(Required) Model(Required) UmbrellaList information for all persons living in the household of driving age. Add RemoveFor each driver include – Name, Date of Birth, DL Number, Accidents and/or tickets in last 5 years. Skip this if all drivers are already listed in the auto section of this form.Should any drivers be EXLUDED? HiddenIn 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 owner occupied homes do you own?(Required)How many rental properties do you own?(Required)How many home/renters claims have you made in the last 5 years?(Required)How many vehicles do you own?(Required)How many auto claims have you made in the last 5 years?(Required)Any drivers on your auto policy have an at-fault accident in the last 5 years?(Required) Yes No Do you own any motor homes?(Required) Yes No Do you own any vacant land?(Required) Yes No How many acres?Do you own any of the following items?(Required) Boat/Yacht Motorcycle ATV Golf Cart Vacant Land Business None of the Above Please provide the current insurance declarations pages for all applicable exposures (auto, home, watercraft, motorhome, motorcycle, etc.)Max. file size: 100 MB. Boat InformationBoat Year Boat Make Boat Model Motor Type(Required) Inboard Outboard How many motors?(Required)123Motor #1 Year(Required) Motor #1 Make(Required) Motor #1 Model Motor #2 Model(Required) Motor #2 Make(Required) Motor #2 Year Motor #3 Year(Required) Motor #3 Make(Required) Motor #3 Model What is the value of the boat and motors?Do you own a boat trailer?(Required) Yes No Trailer Year(Required) Trailer Make(Required) Trailer Model(Required) What is the value of the trailer?Hull Number Top Speed (MPH)(Required)Boat Length(Required)Boat is used for racing?(Required) Yes No Where is boat stored when not in use?(Required) Primary Residence Marina – Slip Marina – Dry Stack Storage Facility – On Trailer Other Where is boat stored? Zip code where boat is storedPlease enter a number less than or equal to 99999.Have you completed a boaters safety course in the last 3 years? Yes No How many years of boating experience do you have? Golf CartYear(Required) Make(Required) Model(Required) Primary Use Within Community Golfing Public Roads (Requires Registration & Tag) Select AllFuel Type Electric Gas Recreational VehicleRV Type 5th Wheel Motorcoach Other Year(Required) Make(Required) Model(Required) Number Current Address (No PO Boxes)(Required) 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 residence student housing? If it is an apartment, please list the square feet of the unit. Number of Permanent Residents Value of all personal property stored at address What Floor do you live on?1st2nd3rd or Above Please upload any insurance documents and/or inspection reports. Drop files here or Select files Max. file size: 100 MB, Max. files: 5. Consent(Required) Reliant Insurance Services may contact me via phone call, email and text message.
