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Critical Agency Automations – PL Intake

*StakWise – PL Intake

Step 1 of 13

7%

Primary Insured Information

Name(Required)
MM slash DD slash YYYY
Marital Status
Group

Spouse Information

Spouse Name
MM slash DD slash YYYY
How did you hear about us?
Referred By Name
What type of insurance can we quote for you?(Required)
New purchase or already own the condo/home?
MM slash DD slash YYYY
How do you use the condo?
Current Address (No PO Boxes)(Required)
Address of Property Being Purchased
Would you like to add a different mailing address?
Mailing Address

Home/Condo Information

MM slash DD slash YYYY
Bedrooms
# of stories
Garage
Additional Structures
More than 5 acres?
Fireplace
Swimming Pool
Swimming Pool Enclosed/Fenced?
Diving Board or Slide?
Gated Community?
Monitored Burglar/Fire Alarm?
Solar Panels
How Many Solar Panels?
Dog(s)?
Dog Breeds
If mixed please indicate type of mix.
Any bite history or security training?
Are you aware of any previous settlement or sinkhole issues on the property?
Have you had any home or renter's insurance claims in the past 5 years?

Home Information Continued

MM slash DD slash YYYY
MM slash DD slash YYYY
Liability
Medical Payments
MM slash DD slash YYYY
Scheduled Personal Property
Valuable Items List (Click the + to add additional items)
Item Description
Replacement Value
Purchase Date
 
Please list each item and include an appraised/estimated value. Only one item per row please.

Auto Information

Total Drivers in Home
Total Vehicles in Home

Driver #2

Name
MM slash DD slash YYYY
Relationship to you

Driver #3

Name
MM slash DD slash YYYY
Relationship to you

Driver #4

Name
MM slash DD slash YYYY
Relationship to you

Driver #5

Name
MM slash DD slash YYYY
Relationship to you

Auto Coverage Info

Liability Limits
UM/UIM
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Rental Reimbursement
PIP or Medical
PIP or Medical

Vehicle #1

Business Use
Rideshare or Delivery?

Vehicle #2

Business Use
Rideshare or Delivery
Rental Reimbursement
Rental Reimbursement
Comprehensive Deductible
Collision Deductible

Vehicle #3

Business Use
Rideshare or Delivery
Rental Reimbursement
Rental Reimbursement
Comprehensive Deductible
Collision Deductible

Vehicle #4

Business Use
Rideshare or Delivery
Rental Reimbursement
Rental Reimbursement
Comprehensive Deductible
Collision Deductible

Vehicle #5

Business Use
Rideshare or Delivery
Rental Reimbursement
Rental Reimbursement
Comprehensive Deductible
Collison Deductible

Investment Property

Address
Property Status

Motorcycle/Slingshot/ATV

Name of Primary Driver
Vehicle Type
Is Vehicle Used for Racing?
Current Motorcycle License
Has Driver Completed Safety Course?

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.
This includes primary, secondary, vacation, rental and investment properties.
Any drivers on your auto policy have an at-fault accident in the last 5 years?
Do you own any of the following items?

Boat Information

Where is boat stored?
Motor Type
Boat is used for racing?
Do you own a boat trailer?

Golf Cart

Primary Use
Fuel Type

Recreational Vehicle

RV Type
Max. file size: 100 MB.
Consent(Required)

Company

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