1StakWise – Intake Form – Extra Mile – PL NEW Step 1 of 26 3% Assigned AdvisorBrooke HenleyMatthew LeeNiki HenleyHow did you hear about us?Realtor ReferralMortgage ReferralCustomer ReferralGoogleFacebookWebsiteCurrent CustomerInternal Referral (Office Use Only)Internal Referral SourcesAAA InsuranceAAA Prior CustCarrier DirectCross-SellCurrent CustomerCustomer ReferCustomer ReferralDavis LawExtra Mile WebsiteFacebookFamilyFRMS- Gordon, TGold StarGold StarGoogle/Search EngineIAOAIns Agnt-UnknownInstagramLinkedInMtg-1st UnitedMtg-ArvestMtg-Flat BrnchMtg-GatewayMtg-Nw Am FundMtg-Pro MtgMtg-UFFCMtg-UFFC-TahlMtg-unknownMtg-ZfgNetwking eventNetworkingOLT-B. ParkerPersonal FrndProfessional ReferralRealtorRemarketRewriteRltr- OtherRltr-Chin&CohnRltr-Cnt21Rltr-Coldw BnkRltr-EXPRltr-Klr WlmsSF-BillingsSF-Bryan SmithSF-S. LaneSF-T.BledsoeWalk-inWinbackWho Referred You? What type of insurance can we quote for you? Auto Home Condo Mobile Home Umbrella Rental Property Motorcycle/Slingshot/ATV Golf Cart Boat RV Other What other type of insurance can we quote for you? Primary Contact InformationName First Last PhoneEmail Date of Birth Month Day Year SSN Occupation Marital Status Single Married Divorced Widowed Spouse InformationSpouse will be considered driver #2 if quoting auto.Name First Last PhoneEmail Occupation Date of Birth Month Day Year SSN Current address or location of home to be insured 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 CountyAdairAlfalfaAtokaBeaverBeckmanBlaineBryanCaddoCanadianCarterCherokeeChoctawCimarronClevelandCoalComancheCottonCraigCreekCusterDelawareDeweyEllisGarfieldGarvinGradyGrantGreerHarmonHarperHaskellHughesJacksonJeffersonJohnsonKayKingfisherKiowaLatimerLeLincolnLoganLoveMajorMarshallMayesMcClainMcCurtainMcIntoshMurrayMuskogeeNobleNowataOkfuskeeOklahomaOkmulgeeOsageOttawaPawneePaynePittsburgPontotocPottawatomiePushmatahaRogerRogersSeminoleSequoyahStephensTexasTillmanTulsaWagonerWashingtonWashitaWoodsWoodwardYears At Current AddressMailing address different than location address?YesNoMailing 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 Years at current address0-2 Years2-5 Years5+ YearsPrior 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 Home/Condo InformationProperty TypeSingle FamilyMulti FamilyCondoFarm/RanchVacant LandNew purchase or already own the condo/home? New Purchase Already Own How do you use the condo? Primary Residence Secondary Residence Rental Purchase Date/Closing Date Month Day Year Purchase Price Year Home Was BuiltAcresSq Ft# of stories 1 1.5 2 Construction TypeFrameBrick VeneerStone VeneerFrame DetailVinylMetalHardiplankWoodRoof MaterialComposite ShinglesAsphalt ShinglesArchitectural ShinglesMetalTileRoof ShapeHipGableFlatYear Roof UpdatedAny updates to heating, electrical or plumbing? Heating Electrical Plumbing Year Heating UpdatedType of UpdateFull ReplacementPartial UpdateYear Electrical UpdatedType of UpdateFull ReplacementPartial UpdateYear Plumbing Updated?Type of UpdateFull ReplacementPartial UpdateFoundationBasementCrawlspaceSlabFinished Basement %Garage Yes Attached Yes Detached Car Port None Garage 1 Car 2 Car 3 Car 4 Car Detached Structures Yes No Detatched StructureYear BuiltDetached Structure Sq. Footage What Type of Structure?GarageShopShedBarnPool HouseOtherWhat Other Type? Detatched Building ExteriorWoodMetalVinylOtherOther Exterior Material Detatched Structure Roof TypeAsphalt ShingleMetalOtherOther Roof Type Detatched Building Roof AgeDetached Structures Used For Farming Purposes? Yes No Which building and how is it used? Fireplace Yes – Gas Yes – Wood No Woodstove Yes No More than 5 Acres Deck/Patio Yes – Covered Yes – Screened Yes – Enclosed No Deck/Patio SizeBathrooms11.522.533.544.5FlooringWood % Carpet % Ceramic % Vinyl % Wood Laminate % OTHER (FILL IN) Swimming Pool Yes No Swimming Pool Fenced and Locked? Yes No Diving Board or Slide? Yes No Trampoline Yes No Trampoline Has A Net? Yes No Monitored Burglar/Fire Alarm? Local Monitored None Monitored Alarm Company Name Responding Fire Department? Miles to Fire Department?Paid Fire Subscription Required? Yes No Unknown Fire Protection Class Any Pets?CatDogCat & DogOtherNoDog Breeds Add RemoveIf mixed please indicate type of mix.Any bite history or security training? Yes No Farming Operations? Yes No Any Horses? Yes No How Many?Any Cattle? Yes No How Many?Any Other Livestock? Yes No Types of LivestockLivestockHow Many Add Remove Mobile HomeWidth Length Tied Down Yes No In Approved Mobile Home Park? Yes No Name of Park? On Private Land? Yes No Manufacturer Model Serial # Any attached additions? If so, what? Done by professional? Yes No Condition of Mobile Excellent Good Poor If insured pays, how do they prefer to pay: Full Pay Two Pay Four Pay Monthly Could you send a front/back photo of your home if we write your insurance? Yes No New purchase or already own the condo/home? New Purchase Already Own How do you use the condo? Primary Residence Secondary Residence Rental Purchase Date/Closing Date Month Day Year Purchase Price Year Home Was BuiltAcresSq Ft# of stories 1 1.5 2 Construction TypeFrameBrick VeneerStone VeneerFrame DetailVinylMetalHardiplankWoodRoof MaterialComposite ShinglesAsphalt ShinglesArchitectural ShinglesMetalTileRoof ShapeHipGableFlatYear Roof UpdatedAny updates to heating, electrical or plumbing? Heating Electrical Plumbing Year Heating UpdatedType of UpdateFull ReplacementPartial UpdateYear Electrical UpdatedType of UpdateFull ReplacementPartial UpdateYear Plumbing Updated?Type of UpdateFull ReplacementPartial UpdateFoundationBasementCrawlspaceSlabFinished Basement %Garage Yes Attached Yes Detached Car Port None Garage 1 Car 2 Car 3 Car 4 Car Detached Structures Yes No Detatched StructureYear BuiltDetached Structure Sq. Footage What Type of Structure?GarageShopShedBarnPool HouseOtherWhat Other Type? Detatched Building ExteriorWoodMetalVinylOtherOther Exterior Material Detatched Structure Roof TypeAsphalt ShingleMetalOtherOther Roof Type Detatched Building Roof AgeDetached Structures Used For Farming Purposes? Yes No Which building and how is it used? More than 5 acres? Yes No Fireplace Yes – Gas Yes – Wood No Woodstove Yes No Deck/Patio Yes – Covered Yes – Screened Yes – Enclosed No Deck/Patio SizeBathrooms11.522.533.544.5FlooringWood % Carpet % Ceramic % Vinyl % Wood Laminate % OTHER (FILL IN) Swimming Pool Yes No Swimming Pool Fenced and Locked? Yes No Diving Board or Slide? Yes No Trampoline Yes No Trampoline Has A Net? Yes No Monitored Burglar/Fire Alarm? Local Monitored None Monitored Alarm Company Name Responding Fire Department? Miles to Fire Department?Paid Fire Subscription Required? Yes No Unknown Fire Protection Class Any Pets?CatDogCat & DogOtherNoDog Breeds Add RemoveIf mixed please indicate type of mix.Any bite history or security training? Yes No Farming Operations? Yes No Any Horses? Yes No How Many?Any Cattle? Yes No How Many?Any Other Livestock? Yes No Types of LivestockLivestockHow Many Add Remove Scheduled Personal Property Jewelry Furs Firearms Art Cameras Musical Instruments Other Total Value of Jewelry Owned?Total Value of Firearms Owned?Total Value of Art/Cameras/Furs/Musical Instruments Owned?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 NotesFarmingFarming Type Annual Farming IncomeCurrent Carrier InformationCurrent Carrier Policy Expiration MM slash DD slash YYYY Dwelling LimitPersonal Property LimitLiability LimitDeductibleCurrent PremiumEscrowed Yes No Mortgage Company Have there been any home claims in the last 5 years? Yes No Claims Add RemoveInclude Date of claim, Type of claim (wind/hail/water/lightning/other), Amount paid. Auto InformationTotal Drivers in Home 1 2 3 4 5 Total Vehicles in Home 1 2 3 4 5 Vehicle #1Vehicle Year Make Model VIN Comprehensive Deductible $0 $250 $500 $750 $1,000 $1,500 Decline Comp Collision Deductible $0 $250 $500 $750 $1,000 $1,500 Decline Collision Business Use Yes No Rideshare or Delivery? Yes No Roadside Yes Decline Rental Reimbursement Decline $50/Day $75/Day $100/Day Vehicle #2Vehicle Year Vehicle Make Vehicle Model VIN Comprehensive Deductible $0 $250 $500 $750 $1,000 $1,500 Decline Collision Collision Deductible $0 $250 $500 $750 $1,000 $1,500 Decline Comp Business Use Yes No Rideshare or Delivery Yes No Roadside Yes Decline Rental Reimbursement Decline $50/Day $75/Day $100/Day Vehicle #3Vehicle Year Vehicle Make Vehicle Model VIN Business Use Yes No Rideshare or Delivery Yes No Roadside Yes Decline Rental Reimbursement Decline $50/Day $75/Day $100/Day Comprehensive Deductible $0 $250 $500 $750 $1,000 $1,500 Decline Comprehensive Collision Deductible $0 $250 $500 $750 $1,000 $1,500 Decline Collision Vehicle #4Vehicle Year Vehicle Make Vehicle Model VIN Business Use Yes No Rideshare or Delivery Yes No Roadside Yes Decline Rental Reimbursement Decline $50/Day $75/Day $100/Day Comprehensive Deductible $0 $250 $500 $750 $1,000 $1,500 Decline Comp Collision Deductible $0 $250 $500 $750 $1,000 $1,500 Decline Collision Vehicle #5Vehicle Year Vehicle Make Vehicle Model VIN Business Use Yes No Rideshare or Delivery Yes No Roadside Yes No Rental Reimbursement $50/Day $75/Day $100/Day Comprehensive Deductible $0 $250 $500 $750 $1,000 $1,500 Decline Comp Collison Deductible $0 $250 $500 $750 $1,000 $1,500 Decline Collision Driver #1 (Named Insured)Drivers License Any tickets or accidents in the last 5 years?DateDescription Add Remove Driver #2Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY SSNAny tickets or accidents in the last 5 years?DateDescription Add RemoveDrivers License # Drivers License Relationship to you Spouse Child Parent Other Occupation Any tickets or accidents in the last 5 years?DateDescription Add Remove Driver #3Name First Last PhoneEmail Date of Birth Month Day Year SSNDrivers License Relationship to you Spouse Child Parent Other Occupation Student Yes No Good Student Disocunt (GPA) Any tickets or accidents in the last 5 years?DateDescription Add Remove Driver #4Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY SSNDrivers License Relationship to you Spouse Child Parent Other Occupation Student Yes No Good Student Disocunt (GPA) Any tickets or accidents in the last 5 years?DateDescription Add Remove Driver #5Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY SSNDrivers License Relationship to you Spouse Child Parent Other Occupation Student Yes No Good Student Disocunt (GPA) Any tickets or accidents in the last 5 years?DateDescription Add Remove Current Auto Policy InformationLiability 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 $500,000/$500,000/$500,000 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 Decline Med Pay $1,000 $5,000 $10,000 $25,000 Do you currently have Gap Coverage? Yes No Current Auto Insurer Name Current Policy Expiration Date MM slash DD slash YYYY Length of Time with Current Auto Insurer Towing/Rental Reimbursement Yes No Current Monthly Auto Premium Pay Plan PreferredFull Pay2 Pay4 PayMonthly Rental PropertyRental Property 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 CountyAdairAlfalfaAtokaBeaverBeckmanBlaineBryanCaddoCanadianCarterCherokeeChoctawCimarronClevelandCoalComancheCottonCraigCreekCusterDelawareDeweyEllisGarfieldGarvinGradyGrantGreerHarmonHarperHaskellHughesJacksonJeffersonJohnsonKayKingfisherKiowaLatimerLeLincolnLoganLoveMajorMarshallMayesMcClainMcCurtainMcIntoshMurrayMuskogeeNobleNowataOkfuskeeOklahomaOkmulgeeOsageOttawaPawneePaynePittsburgPontotocPottawatomiePushmatahaRogerRogersSeminoleSequoyahStephensTexasTillmanTulsaWagonerWashingtonWashitaWoodsWoodwardShort-term rental? (VRBO, Air BnB, etc.)YesNoDays rented per yearOccupany StatusOwnerTenant(s)BothDays owner occupied per yearPersonal Property Coverage RequestedYear BuiltUnder Construction?YesNoSquare FeetStories11.52Construction TypeFrameMasonryFire ResistiveWhat type of siding?WoodVinylRoof TypeComposition ShinglesMetalWoodTileAge of roofFoundationSlabCrawlspaceGarage1c1.5c2c3cNo GarageGarage TypeAttachedDetachedCar Port# of bathsAny unfinished areas in your home?YesNoPlease specify the unfinished area(s) Floor TypeWood %Carpet %Ceramic %Vinyl %Laminate %OTHER (FILL IN) FireplaceYes – GasYes – WoodNoWood Burning StoveYesNoWas this installed by a professional? Central Heat/AirYesNoHeat/Air Type? Alarm Smoke alarm Dead bolt Monitored fire & burglar alarm Responding Fire Dept. Miles to Fire Dept. PC AnimalsYesNoWhat kind of animals? TrampolineYesNoTrampoline Safety Fenced Netting Swimming PoolYesNoPool Safety Fenced Locked Condition of homeExcellentVery GoodGoodPoorCurrent Carrier Motorcycle/ATVName of Primary Driver First Last Was vehicle purchased new? Yes No Current Carrier Drivers License Licensed Motorcycle Endorsement Yes No Has Driver Completed Safety Course? Yes No Tickets or accidents in last 5 years? Add RemoveYears ExperienceVehicle Type Motorcycle Slingshot ATV Number of Wheels234UsagePleasureRacingCommutingYear Make Model VIN CC'sCurrent Carrier 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?Do you own any of the following items? Boat/Yacht Motorcycle ATV Golf Cart Vacant Land Business Boat InformationNumber of Watercraft looking to Insure:123Primary Operator First Last Years boating experienceOther Operator InformationNameDate of BirthMarital StatusYears Experience Add RemoveList any operator in or outside the household with regular access to insured watercraft more than 12 times per yearCurrent Carrier Expiration Date MM slash DD slash YYYY Boat #1HIN # Year Make Model Boat ValueInclude value of permanent/portable boating equipmentPurchase PriceYear Purchased Propulsion type Inboard Outboard Inboard/Outboard Jet Non-powered Number of enginesBoat LengthHull material Total horsepowerExcluding trolling and kicker motorsMaximum SpeedMPHEnhanced performance modifications Add RemoveBlowers, superchargers, etc.Is boat used for racing?YesNoStorage zip codeWhere is boat stored?Primary ResidenceMarina – SlipOtherDo you own a boat trailer?YesNoValue of trailerYear purchasedMulti-OwnerNoYesMore than one owner, not in the same householdBoat #1 Coverage InformationHull Coverage (Comp & Collision)Total Loss Replacement (new boats only)Agreed ValueActual Cash ValueHull Deductible (Comp & Collision)$250$500$1,000$2,500$5,000Liability coverage limitRoadside AssistanceYesNoUninsured/Underinsured Boater CoverageYesNoMedical Payments Coverage$1,000$2,500$5,000$7,500$10,000$25,000Fishing Equipment Coverage$1,000$2,500$5,000$7,500$10,000$25,000Primary Personal Effects Coverage$1,000$2,000$3,000$4,000$5,000 Boat #2Year Make Model Boat ValueInclude value of permanent/portable boating equipmentPurchase PriceYear Purchased HIN # Propulsion type Inboard Outboard Inboard/Outboard Jet Non-powered Number of enginesBoat LengthHull material Total horsepowerExcluding trolling and kicker motorsMaximum SpeedMPHEnhanced performance modifications Add RemoveBlowers, superchargers, etc.Is boat used for racing?YesNoStorage zip codeWhere is boat stored?Primary ResidenceMarina – SlipOtherDo you own a boat trailer?YesNoValue of trailerYear purchasedMulti-OwnerYesNoMore than one owner, not in the same householdBoat #2 Coverage InformationHull Coverage (Comp & Collision)Total Loss Replacement (new boats only)Agreed ValueActual Cash ValueHull Deductible (Comp & Collision)$250$500$1,000$2,500$5,000Liability coverage limitRoadside AssistanceYesNoUninsured/Underinsured Boater CoverageYesNoMedical Payments Coverage$1,000$2,500$5,000$7,500$10,000$25,000Fishing Equipment Coverage$1,000$2,500$5,000$7,500$10,000$25,000Primary Personal Effects Coverage$1,000$2,000$3,000$4,000$5,000 Boat #3Year Make Model Boat ValueInclude value of permanent/portable boating equipmentPurchase PriceYear Purchased HIN # Propulsion type Inboard Outboard Inboard/Outboard Jet Non-powered Number of enginesBoat LengthHull material Total horsepowerExcluding trolling and kicker motorsMaximum SpeedMPHEnhanced performance modifications Add RemoveBlowers, superchargers, etc.Is boat used for racing?YesNoStorage zip codeWhere is boat stored?Primary ResidenceMarina – SlipOtherDo you own a boat trailer?YesNoValue of trailerYear purchasedMulti-OwnerYesNoMore than one owner, not in the same householdBoat #3 Coverage InformationHull Coverage (Comp & Collision)Total Loss Replacement (new boats only)Agreed ValueActual Cash ValueHull Deductible (Comp & Collision)$250$500$1,000$2,500$5,000Liability coverage limitRoadside AssistanceYesNoUninsured/Underinsured Boater CoverageYesNoMedical Payments Coverage$1,000$2,500$5,000$7,500$10,000$25,000Fishing Equipment Coverage$1,000$2,500$5,000$7,500$10,000$25,000Primary Personal Effects Coverage$1,000$2,000$3,000$4,000$5,000 Golf CartYear Make Model Primary Use Transportation Golfing Fuel Type Electric Gas Recreational VehicleYears RV Operating Experience RV TypeMotor HomeTravel TrailerMotor HomeClass AClass BClass CBus ConversionToter HomeTravel TrailerConventionalPop Up5th WheelTruck CamperYear Manufacturer Model/Series Body Style Value of RV Length of Ownership Garaging Zip Code Vehicle Use < 30 Days 30-150 Days > 150 Days Primary Residence RV (Full Timer) Yes No Prior RV Insurance Yes No Prior Carrier Expiration Date MM slash DD slash YYYY Settlement Options Total Loss Replacement (new RVs up to two model years old) Actual Cash Value Agreed Value Physical Damage Deductibles $250 $500 $1,000 $2,500 Windshield Coverage Yes No Medical Payments Coverage $1,000 $2,500 $5,000 $10,000 Liability Coverage Limits Emergency Expense Coverage $750 (included with Physical Damage) $2,000 $7,500 (Full Timer’s only) UM/UIM Coverage Limits Vacation Liability ($10,000 included—up to $500,000) Personal Effects Coverage ($1,000 – $99,000) Roadside Assistance Yes No Please upload current policy documents if you have them available.Max. file size: 100 MB.Consent(Required) Extra Mile Insurance Solutions may contact me via phone call, email and text message.I agree to the Extra Mile Insurance Solutions privacy policy https://www.extramileins.com/privacy-policy/ and I give Extra Mile Insurance Solutions permission to contact me by phone, email and text message.CAPTCHA
