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Extra Mile PL Intake

1StakWise – Intake Form – Extra Mile – PL NEW

Step 1 of 26

3%
What type of insurance can we quote for you?

Primary Contact Information

Name
Date of Birth
Marital Status

Spouse Information

Spouse will be considered driver #2 if quoting auto.
Name
Date of Birth
Current address or location of home to be insured
Mailing Address
Prior Address

Home/Condo Information

New purchase or already own the condo/home?
How do you use the condo?
Purchase Date/Closing Date
# of stories
Any updates to heating, electrical or plumbing?
Garage
Garage
Detached Structures

Detatched Structure

Detached Structures Used For Farming Purposes?
Fireplace
Woodstove
Deck/Patio

Flooring

Swimming Pool
Swimming Pool Fenced and Locked?
Diving Board or Slide?
Trampoline
Trampoline Has A Net?
Monitored Burglar/Fire Alarm?
Paid Fire Subscription Required?
Dog Breeds
If mixed please indicate type of mix.
Any bite history or security training?
Farming Operations?
Any Horses?
Any Cattle?
Any Other Livestock?
Types of Livestock
Livestock
How Many
 

Mobile Home

Tied Down
In Approved Mobile Home Park?
On Private Land?
Done by professional?
Condition of Mobile
If insured pays, how do they prefer to pay:
Could you send a front/back photo of your home if we write your insurance?
New purchase or already own the condo/home?
How do you use the condo?
Purchase Date/Closing Date
# of stories
Any updates to heating, electrical or plumbing?
Garage
Garage
Detached Structures

Detatched Structure

Detached Structures Used For Farming Purposes?
More than 5 acres?
Fireplace
Woodstove
Deck/Patio

Flooring

Swimming Pool
Swimming Pool Fenced and Locked?
Diving Board or Slide?
Trampoline
Trampoline Has A Net?
Monitored Burglar/Fire Alarm?
Paid Fire Subscription Required?
Dog Breeds
If mixed please indicate type of mix.
Any bite history or security training?
Farming Operations?
Any Horses?
Any Cattle?
Any Other Livestock?
Types of Livestock
Livestock
How Many
 
Scheduled Personal Property
Valuable Items List (Click the + to add additional items)
Please list each item and include an appraised/estimated value. Only one item per row please.

Farming

Current Carrier Information

MM slash DD slash YYYY
Escrowed
Have there been any home claims in the last 5 years?
Claims
Include Date of claim, Type of claim (wind/hail/water/lightning/other), Amount paid.

Auto Information

Total Drivers in Home
Total Vehicles in Home

Vehicle #1

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

Vehicle #2

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

Vehicle #3

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

Vehicle #4

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

Vehicle #5

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

Driver #1 (Named Insured)

Any tickets or accidents in the last 5 years?
Date
Description
 

Driver #2

Name
MM slash DD slash YYYY
Any tickets or accidents in the last 5 years?
Date
Description
 
Relationship to you
Any tickets or accidents in the last 5 years?
Date
Description
 

Driver #3

Name
Date of Birth
Relationship to you
Student
Any tickets or accidents in the last 5 years?
Date
Description
 

Driver #4

Name
MM slash DD slash YYYY
Relationship to you
Student
Any tickets or accidents in the last 5 years?
Date
Description
 

Driver #5

Name
MM slash DD slash YYYY
Relationship to you
Student
Any tickets or accidents in the last 5 years?
Date
Description
 

Current Auto Policy Information

Liability Limits
UM/UIM
Med Pay
Do you currently have Gap Coverage?
MM slash DD slash YYYY
Towing/Rental Reimbursement

Rental Property

Rental Property Address

Floor Type

Alarm
Trampoline Safety
Pool Safety

Motorcycle/ATV

Name of Primary Driver
Was vehicle purchased new?
Licensed Motorcycle Endorsement
Has Driver Completed Safety Course?
Tickets or accidents in last 5 years?
Vehicle Type

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.
Do you own any of the following items?

Boat Information

Primary Operator
Other Operator Information
Name
Date of Birth
Marital Status
Years Experience
 
List any operator in or outside the household with regular access to insured watercraft more than 12 times per year
MM slash DD slash YYYY

Boat #1

Include value of permanent/portable boating equipment
Propulsion type
Excluding trolling and kicker motors
MPH
Enhanced performance modifications
Blowers, superchargers, etc.
More than one owner, not in the same household

Boat #1 Coverage Information

Boat #2

Include value of permanent/portable boating equipment
Propulsion type
Excluding trolling and kicker motors
MPH
Enhanced performance modifications
Blowers, superchargers, etc.
More than one owner, not in the same household

Boat #2 Coverage Information

Boat #3

Include value of permanent/portable boating equipment
Propulsion type
Excluding trolling and kicker motors
MPH
Enhanced performance modifications
Blowers, superchargers, etc.
More than one owner, not in the same household

Boat #3 Coverage Information

Golf Cart

Primary Use
Fuel Type

Recreational Vehicle

Vehicle Use
RV (Full Timer)
Prior RV Insurance
MM slash DD slash YYYY
Settlement Options
Physical Damage Deductibles
Windshield Coverage
Medical Payments Coverage
Emergency Expense Coverage
Roadside Assistance
Max. file size: 100 MB.
Consent(Required)
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.

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