PL Intake Form – InsureFit Step 1 of 16 6% Primary Insured InformationName(Required) First Last Phone(Required)Email(Required) Drivers License*Required for all vehicle insurance quotesDate of Birth(Required) MM slash DD slash YYYY Marital Status Single Married Divorced Widowed Education High School Associate Degree Bachelor’s Degree Graduate or Professional Degree Some College Spouse InformationSpouse Name(Required) First Last Spouse Birth Date(Required) MM slash DD slash YYYY Spouse Drivers License*Required for all vehicle insurance quotesSpouse Education High School Associate Degree Bachelor’s Degree Graduate or Professional Degree Some College How did you hear about InsurefitRM? Client Referral Mortgage Referral Realtor Referral Financial Advisor Referral Other Referral Facebook Google Instagram InsurefitRM.com Erie Web Lead Other Referred By Name First Last What type of insurance can we quote for you?(Required) Auto Home Condo Umbrella Investment Property Motorcycle/Slingshot/ATV Golf Cart Boat RV Renters Other What other type of insurance can we quote for you?New purchase or already own the condo/home? New Purchase Already Own How do you use the condo/home? Primary Residence Secondary Residence Rental Current Address (No PO Boxes)(Required) 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 Address of Property Being Purchased(Required) Same as current 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 Would you like to add a different mailing address? Yes No Mailing Address(Required) 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 What type of property are you renting?Single Family HomeMulti-Family Home (Duplex, etc.)ApartmentOtherPlease explainCommunity NameDoes landlord/management require proof of insurance?YesNoWhat floor is your apartment located on?First FloorSecond FloorThird Floor or AboveHow many residents live there full-time?1234+Dog(s)?(Required) Yes No Dog Breeds Add RemoveIf mixed please indicate type of mix. Home InformationSwimming Pool(Required) Yes No Swimming Pool Enclosed/Fenced?(Required) Yes No Diving Board or Slide?(Required) Yes No Trampoline(Required) Yes No Dog(s)?(Required) Yes No Dog Breeds Add RemoveIf mixed please indicate type of mix.Any bite history or security training?(Required) Yes No Home Information ContinuedYear Roof Updated(Required)Year HVAC UpdatedYear Plumbing UpdatedYear Electrical UpdatedClosing Date (If New Purchase) MM slash DD slash YYYY Home Notes/Scheduled Property Auto InformationTotal Drivers in Home(Required) 1 2 3 4 5 Total Vehicles in Home(Required) 1 2 3 4 5 Rental Reimbursement$30 per day$40 per day$50 per dayDeclineRoadside Service Yes No Full Glass Coverage Yes No Do you want to participate in Driving app to save up to 10%? Yes No Your DL#Spouse information will automatically be used for Driver #2Spouse's DL#Driver #2Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers LicenseOccupationRelationship to you Spouse Child Parent Other Additional Discounts Drivers Ed Good Student 3.0 GPA Driver #3Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers LicenseOccupationRelationship to you Spouse Child Parent Other Additional Discounts Drivers Ed Good Student 3.0 GPA Driver #4Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers LicenseOccupationRelationship to you Spouse Child Parent Other Additional Discounts Drivers Ed Good Student 3.0 GPA Driver #5Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers LicenseOccupationRelationship to you Spouse Child Parent Other Additional Discounts Drivers Ed Good Student 3.0 GPA Vehicle #1Vehicle YearVehicle MakeVehicle ModelVINBusiness Use Yes No Rideshare or Delivery Yes No Collision Deductible Decline Collision $250 $500 $1,000 Comprehensive Deductible Decline Comp $250 $500 $1,000 Vehicle #2Vehicle YearVehicle MakeVehicle ModelVINBusiness Use Yes No Rideshare or Delivery Yes No Comprehensive Deductible Decline Comp $250 $500 $1,000 Collision Deductible Decline Collision $250 $500 $1,000 Vehicle #3Vehicle YearVehicle MakeVehicle ModelVINBusiness Use Yes No Rideshare or Delivery Yes No Comprehensive Deductible Decline Comp $250 $500 $1,000 Collision Deductible Decline Collision $250 $500 $1,000 Vehicle #4Vehicle YearVehicle MakeVehicle ModelVINBusiness Use Yes No Rideshare or Delivery Yes No Comprehensive Deductible No Comp $250 $500 $1,000 Collision Deductible No Collision $250 $500 $1,000 Vehicle #5Vehicle YearVehicle MakeVehicle ModelVINBusiness Use Yes No Rideshare or Delivery Yes No Comprehensive Deductible No Comp $250 $500 $1,000 Collison Deductible No Collision $250 $500 $1,000 Investment PropertyAddress(Required) 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 Property Status(Required) Currently Occupied with Tenants Listed For Sale – No Occupants Listed For Rent – No Occupants Undergoing Renovations – Vacant Motorcycle/Slingshot/ATVName of Primary Driver First Last Vehicle Type(Required) Motorcycle Slingshot ATV Current Motorcycle License Yes No Has Driver Completed Safety Course? Yes No YearMakeModelVINValue of Vehicle NewCC's 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.(Required) 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. Umbrella Coverage Amount$1,000,000$2,000,000$5,000,000I'm not sure – Please help Boat InformationWhere is boat stored? Primary Residence Marina – Slip Marina – Dry Stack Other YearMakeModelHull NumberMotor Type Inboard Outboard Top Speed (MPH)Boat LengthDo you own a boat trailer? Yes No Golf CartYearMakeModelVIN or S/NPrimary Use Transportation Golfing Fuel Type Electric Gas Recreational VehicleRV Type 5th Wheel Motorcoach Other Agreed Value ($)YearMakeModel Do you own any of the following items? Boat/Yacht Motorcycle ATV RV Golf Cart Vacant Land Business Rental Property Classic Vehicle None of the above Please upload current policy documents if you have them available.Max. file size: 100 MB. Consent(Required) InsureFit RM may contact me via phone call, email and text message.I agree to the InsureFit RM privacy policy. https://insurefitrm.com/privacy-policy/CAPTCHA
