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insurefit pl intake

PL Intake Form – InsureFit

Step 1 of 16

6%

Primary Insured Information

Name(Required)
*Required for all vehicle insurance quotes
MM slash DD slash YYYY
Marital Status
Education

Spouse Information

Spouse Name(Required)
MM slash DD slash YYYY
*Required for all vehicle insurance quotes
Spouse Education
How did you hear about InsurefitRM?
Referred By Name
What type of insurance can we quote for you?(Required)
New purchase or already own the condo/home?
How do you use the condo/home?
Current Address (No PO Boxes)(Required)
Address of Property Being Purchased(Required)
Would you like to add a different mailing address?
Mailing Address(Required)
Dog(s)?(Required)
Dog Breeds
If mixed please indicate type of mix.

Home Information

Swimming Pool(Required)
Swimming Pool Enclosed/Fenced?(Required)
Diving Board or Slide?(Required)
Trampoline(Required)
Dog(s)?(Required)
Dog Breeds
If mixed please indicate type of mix.
Any bite history or security training?(Required)

Home Information Continued

MM slash DD slash YYYY

Auto Information

Total Drivers in Home(Required)
Total Vehicles in Home(Required)
Roadside Service
Full Glass Coverage
Do you want to participate in Driving app to save up to 10%?

Spouse information will automatically be used for Driver #2

Driver #2

Name
MM slash DD slash YYYY
Relationship to you
Additional Discounts

Driver #3

Name
MM slash DD slash YYYY
Relationship to you
Additional Discounts

Driver #4

Name
MM slash DD slash YYYY
Relationship to you
Additional Discounts

Driver #5

Name
MM slash DD slash YYYY
Relationship to you
Additional Discounts

Vehicle #1

Business Use
Rideshare or Delivery
Collision Deductible
Comprehensive Deductible

Vehicle #2

Business Use
Rideshare or Delivery
Comprehensive Deductible
Collision Deductible

Vehicle #3

Business Use
Rideshare or Delivery
Comprehensive Deductible
Collision Deductible

Vehicle #4

Business Use
Rideshare or Delivery
Comprehensive Deductible
Collision Deductible

Vehicle #5

Business Use
Rideshare or Delivery
Comprehensive Deductible
Collison Deductible

Investment Property

Address(Required)
Property Status(Required)

Motorcycle/Slingshot/ATV

Name of Primary Driver
Vehicle Type(Required)
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.(Required)

Boat Information

Where is boat stored?
Motor Type
Do you own a boat trailer?

Golf Cart

Primary Use
Fuel Type

Recreational Vehicle

RV Type
Do you own any of the following items?
Max. file size: 100 MB.
Consent(Required)
I agree to the InsureFit RM privacy policy. https://insurefitrm.com/privacy-policy/

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