PL Intake Form
Step
1
of
13
7%
Name of person completing Form
(Required)
Location
(Required)
Campbell Insurance
Sharp Insurance
Primary Insured Information
Primary Insured Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Gender
(Required)
Male
Female
Other
Occupation
(Required)
Employer
Marital Status
(Required)
Single
Married
Divorced
Widowed
Domestic Partnership
Spouse Information
Spouse Name
(Required)
First
Last
Spouse Phone
(Required)
Spouse Email
(Required)
Spouse Birth Date
(Required)
MM slash DD slash YYYY
Spouse Occupation
(Required)
How did you hear about us?
Client Referral
Mortgage Referral
Realtor Referral
Financial Advisor Referral
Other Referral
Facebook
Google
Instagram
Other
Referred By Name
First
Last
What type of insurance can we quote for you?
(Required)
Auto
Home
Umbrella
Motorcycle/Slingshot/ATV
Golf Cart
Boat
RV
Other
***If “Home” is chosen AUTO is required to provide a quote for homeowners unless house is seasonal and primary home is not in our service area.***
What other type of insurance can we quote for you?
New purchase or already own the home?
(Required)
New Purchase
Already Own
Current Carrier
(Required)
Current Policy Expiration Date
MM slash DD slash YYYY
Expected Closing Date
MM slash DD slash YYYY
Property Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Time at current address: (YEARS)
<1
1
2
3
More than 3 Years
Prior Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Address of Property Being Purchased
Same as current address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Would you like to add a different mailing address?
Yes
No
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Information
Please select the Home type:
(Required)
Home – Primary
Home – Secondary
Home – Rented to Others
Home – Miscellaneous
Condo – Primary
Condo – Secondary
Condo – Rented to Others
Condo – Miscellaneous
Tenant – Primary
Tenant – Secondary
Tenant – Primary (Manufactured)
Manufactured – Primary
Manufactured – Secondary
Manufactured – Rented to Others
Manufactured – Miscellaneous
Type of Dwelling
(Required)
House
Apartment
Manufactured Home
Row Home/Townhouse
(Required)
Yes
No
Center or End
(Required)
Center
End
Is there a firewall that extends through the roof?
Year (Manufactured)
(Required)
Manufacturer
(Required)
Serial Number
(Required)
Length
(Required)
Width
(Required)
Porches/Decks
(Required)
Yes
No
Please add details of Porch/Deck below:
(Required)
Year Built
Purchase Date
MM slash DD slash YYYY
Sq Ft
Bedrooms
1
2
3
4
5
# of stories
1
1.5
2
Bathrooms
1
1.5
2
2.5
3
3.5
4
4.5
Garage
(Required)
None
1 Car
2 Car
3 Car
4 Car
Garage Type
(Required)
Attached
Detached
Additional Structures
Yes
No
Additional Structure Description
Number of Acres
Wood Burning Stove or Fireplace Insert
(Required)
Yes
No
How often is it cleaned?
(Required)
Fireplace
Yes
No
Diving Board or Slide?
Yes
No
Swimming Pool
(Required)
Yes
No
Swimming Pool Enclosed/Fenced?
(Required)
Yes
No
Monitored Burglar/Fire Alarm?
(Required)
Yes
No
Dog(s)?
(Required)
Yes
No
Dog Breeds
(Required)
Add
Remove
If mixed please indicate type of mix.
Any bite history or security training?
Yes
No
Are you aware of any previous settlement or sinkhole issues on the property?
(Required)
Yes
No
Have you had any home or renter's insurance claims in the past 5 years?
(Required)
Yes
No
Please provide details for your home or renters claims:
Home Information Continued
Exterior Material
Brick Veneer
Clapboard
Vinyl Siding
Stone Veneer
Stucco
Roof Material
(Required)
Shingle
Metal
Year Roof was Installed or Replaced
(Required)
Type of Roof
(Required)
Year Roof Updated
(Required)
Year Electrical Updated
Type of Siding %
(Required)
Siding Type
% of Siding
Add
Remove
Please hit the + sign to add additional types of siding. These need to equal 100%
Foundation
(Required)
Basement/Crawl Space/Slab/Other
% Foundation
Add
Remove
Please hit the + sign to add additional types of Foundation. These need to equal 100%
Finished Basement?
(Required)
Yes
No
% Finished
(Required)
Year Plumbing Updated?
Year HVAC Updated
Current Insurer
Expiration Date
MM slash DD slash YYYY
Dwelling
Current Dwelling Limits
Odometer Reading
Purchase Date
MM slash DD slash YYYY
Wind/Hail Deductible
All Other Perils Deductible
Loss of Use
Other Structures
Personal Property
Liability
$10,000
$15,000
$30,000
$100,000
$300,000
$500,000
Medical Payments
$5,000
$25,000
$50,000
Loan Amount
Closing Date
MM slash DD slash YYYY
Scheduled Personal Property
Artwork
Collectibles
Firearms
Jewelry
Technology
Other
Valuable Items List (Click the + to add additional items)
Item Description
Replacement Value
Purchase Date
Add
Remove
Please list each item and include an appraised/estimated value. Only one item per row please.
Has home been non-renewed in past 3 years?
Yes
No
Home Notes
Auto Information
Current Auto Carrier
(Required)
Current Policy Expiration Date
MM slash DD slash YYYY
Current BI/PD Limits
Total Drivers in Home
1
2
3
4
5
Total Vehicles in Home
1
2
3
4
5
Driver #1
Name
(Required)
First
Last
Phone
Email
Date of Birth
(Required)
MM slash DD slash YYYY
Drivers License
(Required)
Occupation
Relationship to you
(Required)
Spouse
Child
Parent
Domestic Partnership
Other
Any Tickets or Accidents?
(Required)
Yes
No
Ticket / Accident Details
(Required)
Driver #2
Name
(Required)
First
Last
Phone
Email
Date of Birth
(Required)
MM slash DD slash YYYY
Drivers License
(Required)
Occupation
Relationship to you
(Required)
Spouse
Child
Parent
Domestic Partnership
Other
Any Tickets or Accidents?
(Required)
Yes
No
Ticket / Accident Details
(Required)
Driver #3
Name
(Required)
First
Last
Phone
Email
Date of Birth
(Required)
MM slash DD slash YYYY
Drivers License
(Required)
Occupation
Relationship to you
(Required)
Spouse
Child
Parent
Domestic Partnership
Other
Any Tickets or Accidents?
(Required)
Yes
No
Ticket / Accident Details
(Required)
Driver #4
Name
(Required)
First
Last
Phone
Email
Date of Birth
(Required)
MM slash DD slash YYYY
Drivers License
(Required)
Occupation
Relationship to you
(Required)
Spouse
Child
Parent
Domestic Partnership
Other
Any Tickets or Accidents?
(Required)
Yes
No
Ticket / Accident Details
(Required)
Driver #5
Name
(Required)
First
Last
Phone
Email
Date of Birth
(Required)
MM slash DD slash YYYY
Drivers License
(Required)
Occupation
Relationship to you
(Required)
Spouse
Child
Parent
Domestic Partnership
Other
Any Tickets or Accidents?
(Required)
Yes
No
Ticket / Accident Details
(Required)
Auto Coverage Info
Liability Limits
$25,000/$50,000/$25,000
$50,000/$100,000/$50,000
$100,000/$300,000/$100,000
$250,000/$500,000/$250,000
$300,000 CSL
$500,000 CSL
UM/UIM
$25,000/$50,000/$25,000
$50,000/$100,000/$50,000
$100,000/$300,000/$100,000
$250,000/$500,000/$250,000
$300,000 CSL
$500,000 CSL
Vehicle #1
Vehicle Year
(Required)
Make
(Required)
Model
(Required)
VIN
(Required)
Rental Reimbursement
Yes
No
Rental Reimbursement
$30/Day
$50/Day
Comprehensive Deductible
(Required)
Decline Comp
$100
$250
$500
$1,000
Collision Deductible
(Required)
Decline Collision
$100
$250
$500
$1,000
Gap Coverage
(Required)
Yes
No
Primary Operator
(Required)
Yes
No
Usage
(Required)
Pleasure
Commute
Business Use
Annual Mileage (Estimate)
(Required)
Vehicle #2
Vehicle Year
(Required)
Vehicle Make
(Required)
Vehicle Model
(Required)
VIN
(Required)
Rental Reimbursement
Yes
No
Rental Reimbursement
$30/Day
$50/Day
Comprehensive Deductible
(Required)
Decline Comp
$100
$250
$500
$1,000
Collision Deductible
(Required)
Decline Collision
$100
$250
$500
$1,000
Gap Coverage
(Required)
Yes
No
Primary Operator
(Required)
Yes
No
Usage
(Required)
Pleasure
Commute
Business Use
Annual Mileage (Estimate)
(Required)
Vehicle #3
Vehicle Year
(Required)
Vehicle Make
(Required)
Vehicle Model
(Required)
VIN
(Required)
Rental Reimbursement
Yes
No
Rental Reimbursement
$30/Day
$50/Day
Comprehensive Deductible
(Required)
Decline Comp
$100
$250
$500
$1,000
Collision Deductible
(Required)
Decline Collision
$100
$250
$500
$1,000
Gap Coverage
(Required)
Yes
No
Primary Operator
(Required)
Yes
No
Usage
(Required)
Pleasure
Commute
Business Use
Annual Mileage (Estimate)
(Required)
Vehicle #4
Vehicle Year
(Required)
Vehicle Make
(Required)
Vehicle Model
(Required)
VIN
(Required)
Rental Reimbursement
Yes
No
Rental Reimbursement
$30/Day
$50/Day
Comprehensive Deductible
(Required)
No Comp
$100
$250
$500
$1,000
Collision Deductible
(Required)
No Collision
$100
$250
$500
$1,000
Gap Coverage
(Required)
Yes
No
Primary Operator
(Required)
Yes
No
Usage
(Required)
Pleasure
Commute
Business Use
Annual Mileage (Estimate)
(Required)
Vehicle #5
Vehicle Year
(Required)
Vehicle Make
(Required)
Vehicle Model
(Required)
VIN
(Required)
Rental Reimbursement
Yes
No
Rental Reimbursement
$30/Day
$50/Day
Comprehensive Deductible
(Required)
No Comp
$100
$250
$500
$1,000
Collison Deductible
(Required)
No Collision
$100
$250
$500
$1,000
Gap Coverage
(Required)
Yes
No
Primary Operator
(Required)
Yes
No
Usage
(Required)
Pleasure
Commute
Business Use
Annual Mileage (Estimate)
(Required)
Investment Property
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Property Status
Currently Occupied with Tenants
Listed For Sale - No Occupants
Listed For Rent - No Occupants
Undergoing Renovations - Vacant
Motorcycle/Slingshot/ATV
Name 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
Year
Make
Model
VIN
Umbrella
In 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
Boat Information
Where is boat stored?
Primary Residence
Marina - Slip
Marina - Dry Stack
Other
Year
Make
Model
Hull Number
Motor Type
Inboard
Outboard
Top Speed (MPH)
Boat Length
Boat is used for racing?
Yes
No
Do you own a boat trailer?
Yes
No
Golf Cart
Year
Make
Model
Primary Use
Transportation
Golfing
Fuel Type
Electric
Gas
Recreational Vehicle
RV Type
5th Wheel
Motorcoach
Other
Year
Make
Model
Please add any additional information here
Please upload current policy documents if you have them available.
Max. file size: 100 MB.
Please upload current policy documents if you have them available.
Max. file size: 100 MB.
Please upload current policy documents if you have them available.
Max. file size: 100 MB.
Please upload current policy documents if you have them available.
Max. file size: 100 MB.
Please upload current policy documents if you have them available.
Max. file size: 100 MB.
Please upload current policy documents if you have them available.
Max. file size: 100 MB.
If you have more documents or files to upload please select the amount below:
1
2
3
4
5
Consent
(Required)
Campbell Insurance may contact me via phone call, email and text message.
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