Sample Intake Form Platt - Detailed Intake Form Step 1 of 7 14% Prospect Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers License Occupation Policies Being Quoted Auto Home Referred By Name First Last Assigned AgentEllie PlattKristy JohnsonCindy RudinskyKevin CarseConnie FauvieHiddenDate MM slash DD slash YYYY Home InformationProperty 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 Year Home Was BuiltPurchase Date MM slash DD slash YYYY Sq Ft# of Stories11.52# of Bedrooms123456Bathrooms11.522.533.544.5GarageNo Garage1234Additional Structures Yes No Additional Structures Info Please describe the additional structures on your property.More than 5 acres? Yes No Fireplace? Yes No Swimming Pool? Yes No Swimming Pool Fenced? Yes No Diving Board/Slide? Yes No Gated Community? Yes No Monitored Alarm? Yes No Dog(s)? Yes No Dog Breeds Add RemoveSolar Panels? Yes No How Many Solar Panels? Add RemoveExterior MaterialBrick VeneerClapboardVinyl SidingStone VeneerStuccoYear Roof UpdatedYear Electrical UpdatedYear Plumbing Updated?Year HVAC UpdatedHome Coverage LimitsDwellingLoss of UseWind/Hail Deductible All Other Perils Deductible Other StructuresLiabilityLoan AmountPersonal PropertyMedical PaymentsScheduled Personal Property Artwork Collectibles Firearms Jewelry Technology Other 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 Notes Liability Limits$50,000/$100,000/$50,000$100,000/$300,000/$100,000$250,000/$500,000/$250,000$300,000 CSL$500,000 CSLComprehensive Deductible $100 $250 $500 $1,000 No Coverage Collision Deductible $100 $250 $500 $1,000 No Coverage Rental Reimbursement? Yes No Roadside? Yes No PIP/Medical Payments PIP Medical Payments Decline Both UM/UIM$50,000/$100,000/$50,000$100,000/$300,000/$100,000$250,000/$500,000/$250,000$300,000 CSL$500,000 CSLVehicle Year Make Model VIN Business Use Yes No Rideshare and/or Delivery Yes No Total Drivers In Home new 1 2 3 4 5 Total Vehicles In Home 1 2 3 4 5 Driver #2 Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers License Occupation Has A Primary Vehicle 2 Yes No Vehicle #2 InformationVehicle Year Vehicle Make Vehicle Model VIN Comprehensive Deductible $100 $250 $500 $1,000 Decline Comp Collision Deductible $100 $250 $500 $1,000 Decline Comp Business Use Yes No Rideshare and/or Delivery Yes No Driver #3 Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers License Occupation Has A Primary Vehicle 3 Yes No Vehicle #3 InformationVehicle Year Vehicle Make Vehicle Model VIN Comprehensive Deductible $100 $250 $500 $1,000 Decline Comp Collision Deductible $100 $250 $500 $1,000 Decline Comp Business Use Yes No Rideshare and/or Delivery Yes No Driver #4 Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers License Occupation Has A Primary Vehicle 4 Yes No Vehicle #4 InformationVehicle Year Vehicle Make Vehicle Model VIN Comprehensive Deductible $100 $250 $500 $1,000 Decline Comp Collision Deductible $100 $250 $500 $1,000 Decline Comp Business Use Yes No Rideshare and/or Delivery Yes No Driver #5 Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers License Occupation Has A Primary Vehicle 5 Yes No Vehicle #5 InformationVehicle Year Vehicle Make Vehicle Model VIN Collision Deductible $100 $250 $500 $1,000 Decline Comp Comprehensive Deductible $100 $250 $500 $1,000 Decline Comp Business Use Yes No Rideshare and/or Delivery Yes No
