MJB Intake Form Step 1 of 21 4% What type of insurance can we quote for you?(Required) Auto Home Condo Umbrella Investment Property Motorcycle/Slingshot/ATV Golf Cart Boat RV New purchase or already own the condo/home?(Required) New Purchase Already Own How do you use the condo?(Required) Primary Residence Secondary Residence Rental Name(Required) First Last Phone(Required)Email(Required) Drivers License(Required) Date of Birth(Required) MM slash DD slash YYYY SSN Occupation(Required) Marital Status(Required) Single Married Divorced Widowed AgentJohn ToomerDebbie NortonReferred By Name First Last 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?(Required) 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 Year Home Was Built(Required)Purchase Date(Required) MM slash DD slash YYYY Sq Ft(Required)Bedrooms 1 2 3 4 5 # of stories 1 1.5 2 Bathrooms11.522.533.544.5Garage None 1 Car 2 Car 3 Car 4 Car Additional Structures Yes No Additional Structure Description More than 5 acres? Yes No Fireplace Yes No Swimming Pool(Required) Yes No Swimming Pool Enclosed/Fenced?(Required) Yes No Diving Board or Slide?(Required) Yes No Gated Community?(Required) Yes, Passkey Gate Entrance Yes, 24 Hour Manned Gate None Monitored Burglar/Fire Alarm?(Required) Yes No Solar Panels(Required) Yes No How Many Solar Panels? Add RemoveDog(s)?(Required) Yes No Dog Breeds Add RemoveIf mixed please indicate type of mix.Any bite history or security training?(Required) Yes No Are you aware of any previous settlement or sinkhole issues on the property?(Required) Yes No Have you had any home or renter's insurance claims in the past 5 years?(Required) Yes No Exterior MaterialBrick VeneerClapboardVinyl SidingStone VeneerStuccoRoof MaterialComposite ShinglesAsphalt ShinglesArchitectural ShinglesMetalTileYear Roof UpdatedYear Electrical UpdatedYear Plumbing Updated?Year HVAC UpdatedDwellingLoss of UseWind/Hail Deductible All Other Perils Deductible Other StructuresPersonal PropertyLiability $100,000 $300,000 $500,000 Medical Payments $5,000 Second Choice Third Choice Loan AmountClosing Date MM slash DD slash YYYY Scheduled 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 Total Drivers in Home(Required) 1 2 3 4 5 Total Vehicles in Home(Required) 1 2 3 4 5 Liability Limits(Required) $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 $300,000 CSL $500,000 CSL UM/UIM(Required) $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 $300,000 CSL $500,000 CSL Comprehensive Deductible(Required) Decline Comp $100 $250 $500 $1,000 Collision Deductible(Required) Decline Collision $100 $250 $500 $1,000 Rental Reimbursement(Required) Yes No Rental Reimbursement $30/Day $50/Day PIP or Medical Decline Both PIP Medical PIP or Medical $2,500 $5,000 $10,000 Vehicle Year Make Model VIN Business Use(Required) Yes No Rideshare or Delivery?(Required) Yes No Driver #2Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY Drivers License Occupation Relationship to you(Required) Spouse Child Parent Other Does this driver have a primary vehicle?(Required) Yes No Vehicle used by Driver #2Vehicle Year Vehicle Make Vehicle Model VIN Business Use(Required) Yes No Rideshare or Delivery(Required) Yes No Rental Reimbursement Yes No Rental Reimbursement $30/Day $50/Day Comprehensive Deductible Decline Comp $100 $250 $500 $1,000 Collision Deductible Decline Collision $100 $250 $500 $1,000 Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY Drivers License Occupation Relationship to you(Required) Spouse Child Parent Other Does this driver have a primary vehicle?(Required) Yes No Vehicle used by Driver #3Vehicle Year Vehicle Make Vehicle Model VIN Business Use(Required) Yes No Rideshare or Delivery(Required) Yes No Rental Reimbursement Yes No Rental Reimbursement $30/Day $50/Day Comprehensive Deductible Decline Comp $100 $250 $500 $1,000 Collision Deductible Decline Collision $100 $250 $500 $1,000 Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY Drivers License Occupation Relationship to you(Required) Spouse Child Parent Other Does this driver have a primary vehicle?(Required) Yes No Vehicle used by Driver #4Vehicle Year Vehicle Make Vehicle Model VIN Business Use(Required) Yes No Rideshare or Delivery(Required) Yes No Rental Reimbursement Yes No Rental Reimbursement $30/Day $50/Day Comprehensive Deductible No Comp $100 $250 $500 $1,000 Collision Deductible No Collision $100 $250 $500 $1,000 Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY Drivers License Occupation Relationship to you(Required) Spouse Child Parent Other Does this driver have a primary vehicle?(Required) Yes No Vehicle used by driver #5Vehicle Year Vehicle Make Vehicle Model VIN Business Use(Required) Yes No Rideshare or Delivery(Required) Yes No Rental Reimbursement Yes No Rental Reimbursement $30/Day $50/Day Comprehensive Deductible No Comp $100 $250 $500 $1,000 Collison Deductible No Collision $100 $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(Required) First Last Vehicle Type(Required) Motorcycle Slingshot ATV Is Vehicle Used for Racing?(Required) Yes No Current Motorcycle License(Required) Yes No Has Driver Completed Safety Course?(Required) Yes No Year(Required) Make(Required) Model(Required) VIN 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. How many homes do you own?(Required)This includes primary, secondary, vacation, rental and investment properties.How many home/renters claims have you made in the last 5 years?(Required)How many vehicles do you own?(Required)How many auto claims have you made in the last 5 years?(Required)Any drivers on your auto policy have an at-fault accident in the last 5 years?(Required) Yes No Do you own any of the following items?(Required) Boat/Yacht Motorcycle ATV Golf Cart Vacant Land Business Boat InformationWhere is boat stored?(Required) Primary Residence Marina - Slip Marina - Dry Stack Other Year(Required) Make(Required) Model(Required) Hull Number Motor Type(Required) Inboard Outboard Top Speed (MPH)(Required)Boat Length(Required)Boat is used for racing?(Required) Yes No Do you own a boat trailer?(Required) Yes No Golf CartYear Make Model Primary Use Transportation Golfing Fuel Type Electric Gas Recreational VehicleRV Type 5th Wheel Motorcoach Other Year Make Model Please upload current policy documents if you have them available.Max. file size: 100 MB.Consent Reliant Insurance Services may contact me via phone call, email and text message.
