The Myriam Mellen AgencyI will SHOP the best policy for you. I work for YOU, not the carrier! Brightway: Mellen Intake Form Step 1 of 8 12% Prospect Name(Required) First Last Phone(Required)Email(Required) Date of Birth MM slash DD slash YYYY SSNOccupationMarital Status Single Married Widowed Divorced Policies Being Quoted(Required) Auto Home (Existing) Home (New Purchase) How did you hear about the Brightway Mellen Agency?Client ReferralFacebookGoogleLoan OfficerRealtorYouTubeWebsiteOtherSpouse Name First Last Date of Birth MM slash DD slash YYYY PhoneEmail Information For Home Being QuotedCurrent 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 What is the address of the property to be purchased? 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 is this? Primary Secondary Rental Purchase/Closing Date MM slash DD slash YYYY Solar Panels Yes No Number of Solar PanelsDwelling/Purchase PriceHow much coverage is required to rebuild your home?Loan/Mortgage AmountAny valuables you'd like to insure? 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 Driver InformationTotal Drivers In Home 1 2 3 4 5 Type of Driver Rated Excluded Would you like us to bundle your home and auto insurance if possible? Yes No Driver #2Driver #2 First Last Date of Birth MM slash DD slash YYYY Driver Rated or Excluded? Rated Excluded Email PhoneOccupationDriver #3Driver #3 First Last Date of Birth MM slash DD slash YYYY Driver Rated or Excluded? Rated Excluded Email PhoneOccupationDriver #4Driver #4 First Last Driver Rated or Excluded? Rated Excluded Email PhoneOccupationDriver #5Driver #5 First Last Date of Birth MM slash DD slash YYYY Driver Rated or Excluded? Rated Excluded Email PhoneOccupation Total Vehicles In Home 1 2 3 4 5 Vehicle #1Vehicle YearMakeModelVINDo you have a lien holder? Yes No Who is your lien holder?Vehicle #2Vehicle YearVehicle MakeVehicle ModelVINDo you have a lien holder? Yes No Who is the lien holder?Vehicle #3Vehicle YearVehicle MakeVehicle ModelVINDo you have a lien holder? Yes No Who is the lien holder?Vehicle #4Vehicle YearVehicle MakeVehicle ModelVINDo you have a lien holder? Yes No Who is the lien holder? Are all the vehicles registered to the owner? Yes No Which vehicle are you not the registered owner to?Rideshare and/or Delivery Yes No Which vehicle are you designating for Rideshare and/or Delivery?Business Use Yes No Which vehicle is used for Business Use? Collision Deductible $100 $250 $500 $750 $1,000 No Collision Coverage This optional coverage reimburses you for damage to your car that occurs as a result of a collision with another vehicle or other object—e.g., a tree or guardrail—when you’re at fault. While collision coverage will not reimburse you for mechanical failure or normal wear-and-tear on your car, it will cover damage from potholes or from rolling your car.Comprehensive Deductible $100 $250 $500 $750 $1,000 No Comp Coverage This provides coverage against theft and damage caused by an incident other than a collision, such as fire, flood, vandalism, hail, falling rocks or trees and other hazards—even getting hit by an asteroid!Are any of your Vehicles Liability only? Yes No Which vehicle is Liability only? Please upload your current policy documents (if available) Drop files here or Select files Max. file size: 100 MB. Do you have any fears, concerns or expectation regarding your insurance?Do you have any hypothetical claim scenarios or situations in the past that would like to discuss?Consent(Required) I agree to the privacy policy.By checking this box I agree to the Brightway: Mellen Agency privacy policy and provide my consent to be contacted via phone call, email and sms.CAPTCHA