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CL Intake
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PL Renewal
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CL Intake

Gartman – CL Intake Form

"*" indicates required fields

Business Details

Mailing Address:*
Is Physical Address Same As Mailing Address?*
Physical Address:*
MM slash DD slash YYYY
Are You A Contractor?*
Names and % of Ownership for all Officers:*
Full Name
Position
% of Ownership
 

Additional Contractor Details

CL Renewal

Gartman – CL Renewal Form

"*" indicates required fields

Full Name:*
Mailing/Correspondence Address:*
We maintain an extensive network of local professionals to help our clients with many potential needs. Please check any box below for any service you'd like a personal introduction to one of our Channel Partners in that area.
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Max. file size: 100 MB, Max. files: 3.
    PL Intake

    Gartman – PL Intake Form

    Step 1 of 21

    4%

    Primary Insured Information

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

    Spouse Information

    Spouse Name
    MM slash DD slash YYYY
    Spouse Education(Required)
    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?(Required)
    How do you use the condo?(Required)
    Current Address (No PO Boxes)(Required)
    Address of Property Being Purchased(Required)
    Would you like to add a different mailing address?(Required)
    Mailing Address(Required)

    Home Information

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

    Home Information Continued

    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(Required)
    Total Vehicles in Home(Required)
    Liability Limits(Required)
    UM/UIM(Required)
    Comprehensive Deductible(Required)
    Collision Deductible(Required)
    Rental Reimbursement(Required)
    Rental Reimbursement
    PIP or Medical
    PIP or Medical
    Business Use(Required)
    Rideshare or Delivery?(Required)

    Driver #2

    Name(Required)
    MM slash DD slash YYYY
    Relationship to you(Required)

    Driver #3

    Name(Required)
    MM slash DD slash YYYY
    Relationship to you(Required)

    Driver #4

    Name(Required)
    MM slash DD slash YYYY
    Relationship to you(Required)

    Driver #5

    Name(Required)
    MM slash DD slash YYYY
    Relationship to you(Required)

    Vehicle #2

    Business Use(Required)
    Rideshare or Delivery(Required)
    Rental Reimbursement
    Rental Reimbursement
    Comprehensive Deductible
    Collision Deductible

    Vehicle #3

    Business Use(Required)
    Rideshare or Delivery(Required)
    Rental Reimbursement
    Rental Reimbursement
    Comprehensive Deductible
    Collision Deductible

    Vehicle #4

    Business Use(Required)
    Rideshare or Delivery(Required)
    Rental Reimbursement
    Rental Reimbursement
    Comprehensive Deductible
    Collision Deductible

    Vehicle #5

    Business Use(Required)
    Rideshare or Delivery(Required)
    Rental Reimbursement
    Rental Reimbursement
    Comprehensive Deductible
    Collison Deductible

    Investment Property

    Address(Required)
    Property Status(Required)

    Motorcycle/Slingshot/ATV

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

    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.(Required)
    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
    PL Renewal

    Gartman – PL Renewal Form

    Step 1 of 12

    8%
    Name(Required)
    Are you driving for a rideshare or delivery company?(Required)
    Have you started using your vehicle for business?
    (Roofing, real estate, advertisement, etc.)
    Please check all situations that apply to you.(Required)
    MM slash DD slash YYYY
    Updated Address
    Add Driver To Policy
    Remove Driver From Policy
    What is your current marital status?
    What new toy(s) did you purchase?
    List make, model and estimated purchase price for each new toy.
    Year
    Make
    Model
     
    Click the + to add more rows.
    What type of property did you purchase?(Required)
    MM slash DD slash YYYY
    New Property Address(Required)
    Is your business currently insured?
    MM slash DD slash YYYY
    Year/Make/Model of purchased vehicle(s)
    Year
    Make
    Model
     
    Click the + to add rows for additional vehicles.
    MM slash DD slash YYYY
    Year/Make/Model of sold vehicle(s)
    Year
    Make
    Model
     
    Click the + to add rows for additional vehicles.
    Please list the renovations and an approximate cost of each.
    You can use the + button on the right side to add additional rows.
    This field is for validation purposes and should be left unchanged.
    Service Request

    Gartman – Service Form

    Step 1 of 17

    5%
    Name(Required)
    Which Policy Do You Need To Service?(Required)
    Please Select The Home Changes You Need To Make(Required)
    Please Select The Auto Changes You Need To Make(Required)
    New Mortgage Company
    Mortgagee Clause

    Personal Property Coverage

    What type of personal property coverage change would you like to make?
    Please list the specific items that should be added to your policy
    Item Description
    Replacement Value
    Date Purchased
     
    New Mailing Address
    Why are you updating your address?
    Updated Address
    Why are you updating your address?

    Other Changes

    Vehicle Changes

    Which action are you requesting?

    Vehicle to Remove

    Reason For Removal?

    MM slash DD slash YYYY

    Vehicle to Add

    Please double check your entry to make sure it’s correct. Also note VINs never contain the letters L or O (if you see them they are 1 or 0).
    How Will The New Car Be Used?
    The average commuter will drive approximately 13,000 miles a year.
    MM slash DD slash YYYY
    Does Your New Car Need Comprehensive & Collision Coverage?(Required)
    If none, enter “none”

    New Vehicle Deductibles

    What Comprehensive Deductible Would You Like?
    Comprehensive covers everything other than an at fault accident. Ex. Theft, vandalism, a rock cracking your windshield on the freeway, etc.
    What Collision Deductible Would You Like?
    NOTE: The lower the deductible, the higher the premium.

    Add/Remove Driver Information

    Which driver action are you requesting?

    New Driver Information

    MM slash DD slash YYYY
    Does new driver live with you?
    Current High School Student With A 3.0 or Better GPA?
    If the new driver is a high school student with a 3.0 or better GPA, they may qualify for a “good student discount”. You will need to submit proof (last report card).
    New Driver's Address

    Removed Driver Information

    Name
    Is This Person Still A Household Resident?

    Document Request

    MM slash DD slash YYYY

    If you need your documents urgently please click the link below and navigate to your insurance carrier’s website or service phone number.
    If this is not a time-sensitive request our team will have your documents emailed to you in less than 24 business hours.

    Other Change Details

    Business Policy Changes

    Name of person submitting request(Required)
    Business Policy(ies) Needing Service
    Do you need to file a claim or request a COI?
    Max. file size: 100 MB.

    Claim Information

    MM slash DD slash YYYY
    Consent
    Gartman Insurance will use this information to evalute my claim and advise me about filing a claim.
    Agreement(Required)
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