Intake Forms
Personal Lines Intake Form
Commercial Lines Intake Form
Personal Lines Intake Form
Step
1
of
21
4%
Primary Insured Information
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Drivers License
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
SSN
Occupation
Marital Status
(Required)
Single
Married
Divorced
Widowed
Education
(Required)
High School
Associate Degree
Bachelor’s Degree
Graduate or Professional Degree
Some College
Spouse Information
Spouse Name
First
Last
Spouse Phone
Spouse Email
Spouse Birth Date
MM slash DD slash YYYY
Spouse Drivers License
Spouse Education
(Required)
High School
Associate Degree
Bachelor’s Degree
Graduate or Professional Degree
Some College
Spouse Occupation
How did you hear about us?
Client Referral
Mortgage Referral
Realtor Referral
Financial Advisor Referral
Other Referral
Facebook
Google
Instagram
Other
Referred By Name
First
Last
Preferred Advisor
Producer 1
Producer 2
What type of insurance can we quote for you?
(Required)
Auto
Home
Condo
Umbrella
Investment Property
Motorcycle/Slingshot/ATV
Golf Cart
Boat
RV
Other
What other type of insurance can we quote for you?
(Required)
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
Current Address (No PO Boxes)
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Address of Property Being Purchased
(Required)
Same as current address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed 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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Information
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
Bathrooms
1
1.5
2
2.5
3
3.5
4
4.5
Garage
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
Remove
Dog(s)?
(Required)
Yes
No
Dog Breeds
Add
Remove
If 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
Home Information Continued
Exterior Material
Brick Veneer
Clapboard
Vinyl Siding
Stone Veneer
Stucco
Roof Material
Composite Shingles
Asphalt Shingles
Architectural Shingles
Metal
Tile
Year Roof Updated
Year Electrical Updated
Year Plumbing Updated?
Year HVAC Updated
Dwelling
Loss of Use
Wind/Hail Deductible
All Other Perils Deductible
Other Structures
Personal Property
Liability
$100,000
$300,000
$500,000
Medical Payments
$5,000
Second Choice
Third Choice
Loan Amount
Closing 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 Description
Replacement Value
Purchase Date
Add
Remove
Please list each item and include an appraised/estimated value. Only one item per row please.
Home Notes
Auto Information
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 #2
Name
(Required)
First
Last
Phone
Email
Date of Birth
(Required)
MM slash DD slash YYYY
Drivers License
Occupation
Relationship to you
(Required)
Spouse
Child
Parent
Other
Driver #3
Name
(Required)
First
Last
Phone
Email
Date of Birth
(Required)
MM slash DD slash YYYY
Drivers License
Occupation
Relationship to you
(Required)
Spouse
Child
Parent
Other
Driver #4
Name
(Required)
First
Last
Phone
Email
Date of Birth
(Required)
MM slash DD slash YYYY
Drivers License
Occupation
Relationship to you
(Required)
Spouse
Child
Parent
Other
Driver #5
Name
(Required)
First
Last
Phone
Email
Date of Birth
(Required)
MM slash DD slash YYYY
Drivers License
Occupation
Relationship to you
(Required)
Spouse
Child
Parent
Other
Vehicle #2
Vehicle 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
Vehicle #3
Vehicle 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
Vehicle #4
Vehicle 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
Vehicle #5
Vehicle 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 Property
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed 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/ATV
Name 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
Make
Model
VIN
Umbrella
In 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?
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 Information
Where is boat stored?
Primary Residence
Marina – Slip
Marina – Dry Stack
Other
Year
Make
Model
Hull Number
Motor Type
Inboard
Outboard
Top Speed (MPH)
Boat Length
Boat is used for racing?
Yes
No
Do you own a boat trailer?
Yes
No
Golf Cart
Year
Make
Model
Primary Use
Transportation
Golfing
Fuel Type
Electric
Gas
Recreational Vehicle
RV Type
5th Wheel
Motorcoach
Other
Year
Make
Model
Please upload current policy documents if you have them available.
Max. file size: 100 MB.
Consent
SFM Insurance may contact me via phone call, email and text message.
Commercial Lines Intake Form
"
*
" indicates required fields
Business Details
Business Name:
*
Business Entity:
*
FEIN / Tax-ID Number:
Phone Number:
*
Email:
*
Mailing Address:
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is Physical Address Same As Mailing Address?
*
Yes
No
Physical Address:
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Website Address:
Effective Date:
MM slash DD slash YYYY
Are You A Contractor?
*
Yes
No
Brief Description of Operations:
Names and % of Ownership for all Officers:
*
Full Name
Position
% of Ownership
Add
Remove
Year Business Started:
Number of Employees:
Estimated Annual Payroll:
Estimated Annual Revenue:
Additional Contractor Details
Contractors License #
% of work Subcontracted out
% of Residential Work
% of Commercial Work
% of Remodel/Install work
% of New Construction Work
% of Service/Maintenance Work
Do you perform Government/Municipality Work?
Yes
No
Scroll to top
Scroll to top
