PL – Intake Form Step 1 of 13 7% Primary Insured InformationAgent(Required)Allison CoxEric CaplingerJustin MillerLaura RussellScott CoxPrimary Insured Name(Required) First Last Phone(Required)Email(Required) Drivers LicenseDate of Birth(Required) MM slash DD slash YYYY OccupationEmployerMarital Status(Required)SingleMarriedDivorcedWidowedSpouse InformationSpouse Name First Last Spouse PhoneSpouse Email Spouse Birth Date MM slash DD slash YYYY Spouse Occupation How did you hear about us? Client Referral Realtor Referral Facebook Google Other Referred By Name First Last Please Describe "Other"What type of insurance can we quote for you?(Required) Auto Home Condo Umbrella Flood Investment Property Motorcycle/Slingshot/ATV Golf Cart Boat RV Life Insurance Other What other type of insurance can we quote for you?New purchase or already own the condo/home? New Purchase Already Own Expected Closing Date MM slash DD slash YYYY How do you use the condo? 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 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 Home/Condo InformationYear BuiltPurchase Date MM slash DD slash YYYY Sq FtBedrooms 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 DescriptionNumber of AcresDiving Board or Slide? Yes No Swimming Pool(Required) Yes No Swimming Pool Enclosed/Fenced? Yes No Monitored Burglar/Fire Alarm? Yes No Dog(s)?(Required) Yes No Dog Breeds Add RemoveIf mixed please indicate type of mix.Any bite history or security training? Yes No Are you aware of any previous settlement or sinkhole issues on the property? Yes No Have you had any home or renter's insurance claims in the past 5 years? Yes No Home Information ContinuedExterior MaterialBrick VeneerClapboardVinyl SidingStone VeneerStuccoRoof MaterialComposite ShinglesAsphalt ShinglesArchitectural ShinglesMetalTileYear Roof UpdatedYear Electrical UpdatedYear Plumbing Updated?Year HVAC UpdatedCurrent InsurerExpiration Date MM slash DD slash YYYY DwellingCurrent Dwelling LimitsOdometer ReadingPurchase Date MM slash DD slash YYYY Wind/Hail DeductibleAll Other Perils DeductibleLoss of UseOther StructuresPersonal PropertyLiability $10,000 $15,000 $30,000 $100,000 $300,000 $500,000 Medical Payments $5,000 $25,000 $50,000 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)Item DescriptionReplacement ValuePurchase Date Add RemovePlease list each item and include an appraised/estimated value. Only one item per row please.Has home been non-renewed in past 3 years?YesNoHome Notes Auto InformationTotal Drivers in Home 1 2 3 4 5 Total Vehicles in Home 1 2 3 4 5 Driver #2Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Drivers LicensePhoneEmail OccupationRelationship(Required) Spouse Child Parent Domestic Partnership Other Driver #3Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Drivers LicensePhoneEmail OccupationRelationship to you(Required) Spouse Child Parent Domestic Partnership Other Driver #4Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Drivers LicensePhoneEmail OccupationRelationship to you(Required) Spouse Child Parent Domestic Partnership Other Driver #5Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Drivers LicensePhoneEmail OccupationRelationship to you(Required) Spouse Child Parent Domestic Partnership Other Auto Coverage InfoLiability Limits $10,000/$20,000/$10,000 $25,000/$50,000/$25,000 $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 Other UM/UIM $10,000/$20,000/$10,000 $25,000/$50,000/$25,000 $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 Other "Other" Liability Limits"Other" UM/UIMComprehensive Deductible Decline Comp $100 $250 $500 $1,000 Collision Deductible Decline Collision $100 $250 $500 $1,000 Rental Reimbursement Yes No Rental Reimbursement $30/Day $50/Day Roadside Service Yes No Vehicle #1Vehicle Year(Required)Make(Required)Model(Required)VINBusiness Use Yes No Rideshare or Delivery? Yes No Vehicle #2Vehicle Year(Required)Vehicle Make(Required)Vehicle Model(Required)VINBusiness Use Yes No Rideshare or Delivery 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 Vehicle #3Vehicle Year(Required)Vehicle Make(Required)Vehicle Model(Required)VINBusiness Use Yes No Rideshare or Delivery 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 Vehicle #4Vehicle Year(Required)Vehicle Make(Required)Vehicle Model(Required)VINBusiness Use Yes No Rideshare or Delivery 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 Vehicle #5Vehicle Year(Required)Vehicle Make(Required)Vehicle Model(Required)VINBusiness Use Yes No Rideshare or Delivery 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 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 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 Motorcycle Slingshot ATV Is Vehicle Used for Racing? Yes No Current Motorcycle License Yes No Has Driver Completed Safety Course? Yes No YearMakeModelVIN 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. 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?This includes primary, secondary, vacation, rental and investment properties.How many home/renters claims have you made in the last 5 years?How many vehicles do you own?How many auto claims have you made in the last 5 years?Any drivers on your auto policy have an at-fault accident in the last 5 years? Yes No Do you own any of the following items? Boat/Yacht Motorcycle ATV Golf Cart Vacant Land Business Boat InformationWhere is boat stored? Primary Residence Marina - Slip Marina - Dry Stack Other YearMakeModelHull NumberMotor Type Inboard Outboard Top Speed (MPH)Boat LengthBoat is used for racing? Yes No Do you own a boat trailer? Yes No Golf CartYearMakeModelPrimary Use Transportation Golfing Fuel Type Electric Gas Recreational VehicleRV Type 5th Wheel Motorcoach Other YearMakeModel Please add any additional information herePlease upload current policy documents if you have them available.Max. file size: 100 MB.Consent(Required) Manasota Insurance & Wealth Management may contact me via phone call, email and text message.CAPTCHA
