Shepherd Insurance Partners - StakWise

Step 1 of 17

5%

Name(Required)

First Last

Email(Required)

Phone

Which Policy Do You Need To Service?(Required)

Auto Policy

Home Policy

Business Policy

Other

What Other Type of Insurance?(Required)

Please Select The Home Changes You Need To Make(Required)

Change Mortgage Company

Add More Personal Property Coverage

Change Your Mailing Address

File A Claim

Document Request

Other

Billing Inquiry

Please Select The Auto Changes You Need To Make(Required)

Add/Remove/Replace A Car

Add/Remove Driver

Add/Remove/Update Lienholder

Update Your Address

File A Claim

Billing Inquiry

Document Request

Other

New Mortgage Company

Mortage Company Name and Street Address Loan Number City State ZIP Code

Mortgagee Clause

ATIMA

ASAOA

ATIMA/ASAOA

Personal Property Coverage

What type of personal property coverage change would you like to make?

Increase total personal property coverage limit

Add specific item(s) of value (scheduled property)

How much more personal property coverage would you like to add?

Please list the specific items that should be added to your policy

Item Description

Replacement Value

Date Purchased

New Mailing Address

Street Address Address Line 2 City State ZIP Code

Why are you updating your address?

This is my new residence

This is only a mailing address (I still live at my current address)

Updated Address

Street Address Address Line 2 City State ZIP Code

Why are you updating your address?

This is my new residence

This is only a mailing address (I still live at my current address)

Other Changes

Please Specify Your "Other" Changes. Be As Specific As Possible

Vehicle Changes

Which action are you requesting?

Add a new vehicle to my policy

Remove a vehicle from my policy

Replace a vehicle on my policy with a new vehicle

Vehicle to Remove

Which Car Are You Removing? (Yr, Make, Model)

Reason For Removal?

Sold

Other

What day did you stop owning the vehicle?

MM slash DD slash YYYY

Vehicle to Add

What Is The 17 Character VIN# Of Your New Car?

Please double check your entry to make sure it's correct. Also note VINs never contain the letters L or O (if you see them they are 1 or 0).

How Will The New Car Be Used?

Pleasure

Work/School Commute

Business/Commercial (Including Uber and Lyft)

How Many Miles Will This Car Be Driven Annually?

The average commuter will drive approximately 13,000 miles a year.

What Is The Odometer Of Your New Car?

What Date Did You Purchase The Vehicle?

MM slash DD slash YYYY

Does Your New Car Need Comprehensive & Collision Coverage?(Required)

Yes

No

Is There A Lien Holder? If So, Who?

If none, enter "none"

Who Is The Primary Driver?

New Vehicle Deductibles

What Comprehensive Deductible Would You Like?

$250

$500

$1000

Decline Comprehensive Coverage

Comprehensive covers everything other than an at fault accident. Ex. Theft, vandalism, a rock cracking your windshield on the freeway, etc.

What Collision Deductible Would You Like?

$250

$500

$1000

Decline Collision Coverage

NOTE: The lower the deductible, the higher the premium.

Add/Remove Driver Information

Which driver action are you requesting?

Add a new driver to my policy

Remove a driver from my policy

Replace a driver on my policy with a new driver

New Driver Information

New Driver Full Name

New Driver Date of Birth

MM slash DD slash YYYY

New Driver DL#

New Driver's Relation To You

Other Relation

Does new driver live with you?

Yes

No

New Driver's Employer or School

Current High School Student With A 3.0 or Better GPA?

Yes

No

If the new driver is a high school student with a 3.0 or better GPA, they may qualify for a "good student discount". You will need to submit proof (last report card).

New Driver's Address

Street Address Address Line 2 City State ZIP Code

Removed Driver Information

Name

First Last

Reason For Removing Driver

Is This Person Still A Household Resident?

Yes

No

Document Request

Which Document(s) Are You Requesting?

When Do You Need The Document(s)?

MM slash DD slash YYYY

If you need your documents urgently please click the link below and navigate to your insurance carrier's website or service phone number.
If this is not a time-sensitive request our team will have your documents emailed to you in less than 24 business hours.

Other Change Details

Please Specify Your "Other" Changes. Be As Specific As Possible

Business Policy Changes

Business Name(Required)

Name of person submitting request(Required)

First Last

Email(Required)

Phone

Business Policy(ies) Needing Service

BOP

Business Auto/Fleet

Business Liability

Business Property

Cyber Liability

Excess Liability

General Liability

Workers Comp

Other

Other Type of Policy(Required)

Do you need to file a claim or request a COI?

File A Claim

Request A COI

Other Type of Change

Please explain the details of your change reqeust.

Please upload any files required to make the change.

Max. file size: 100 MB.

Claim Information

Date of Loss

MM slash DD slash YYYY

Details of the claim you would like to file.

Consent

I understand that the purpose of completing this form is to inform Advisors Insurance Agency about a claim i would like to file. I also understand that completing this form does not constitute filing a claim with my insurance carrier.

Advisors Insurance Agency will use this information to evalute my claim and advise me about filing a claim.

Agreement(Required)

I understand that submitting this form does not actually make any changes to my policy. This form is only a request and no changes to my policy are effective until I receive confirmation from Sheperd Insurance Partners Inc.

Shepherd Insurance Partners

Service Form

CL Intake

CL Renewal

PL Intake

PL Renewal

Service Form

Step 1 of 13

7%

Name(Required)

First Last

Email(Required)

Phone

Which Policy Do You Need To Service?(Required)

Auto Policy

Home Policy

Business Policy

Other

What Other Type of Insurance?(Required)

Please Select The Home Changes You Need To Make(Required)

Change Mortgage Company

Add More Personal Property Coverage

Change Your Mailing Address

File A Claim

Document Request

Other

Billing Inquiry

Please Select The Auto Changes You Need To Make(Required)

Add/Remove/Replace A Car

Add/Remove Driver

Add/Remove/Update Lienholder

Update Your Address

File A Claim

Billing Inquiry

Document Request

Other

New Mortgage Company

Mortage Company Name and Street Address Loan Number City State ZIP Code

Mortgagee Clause

ATIMA

ASAOA

ATIMA/ASAOA

Personal Property Coverage

What type of personal property coverage change would you like to make?

Increase total personal property coverage limit

Add specific item(s) of value (scheduled property)

How much more personal property coverage would you like to add?

Please list the specific items that should be added to your policy

Item Description

Replacement Value

Date Purchased

New Mailing Address

Street Address Address Line 2 City State ZIP Code

Why are you updating your address?

This is my new residence

This is only a mailing address (I still live at my current address)

Updated Address

Street Address Address Line 2 City State ZIP Code

Why are you updating your address?

This is my new residence

This is only a mailing address (I still live at my current address)

Other Changes

Please Specify Your "Other" Changes. Be As Specific As Possible

Vehicle Changes

Which action are you requesting?

Add a new vehicle to my policy

Remove a vehicle from my policy

Replace a vehicle on my policy with a new vehicle

Vehicle to Remove

Which Car Are You Removing? (Yr, Make, Model)

Reason For Removal?

Sold

Other

What day did you stop owning the vehicle?

MM slash DD slash YYYY

Vehicle to Add

What Is The 17 Character VIN# Of Your New Car?

Please double check your entry to make sure it’s correct. Also note VINs never contain the letters L or O (if you see them they are 1 or 0).

How Will The New Car Be Used?

Pleasure

Work/School Commute

Business/Commercial (Including Uber and Lyft)

How Many Miles Will This Car Be Driven Annually?

The average commuter will drive approximately 13,000 miles a year.

What Is The Odometer Of Your New Car?

What Date Did You Purchase The Vehicle?

MM slash DD slash YYYY

Does Your New Car Need Comprehensive & Collision Coverage?(Required)

Yes

No

Is there a lienholder?(Required)

Yes

No

Lienholder Name

Lienholder Address

Street Address Address Line 2 City State ZIP Code

Who Is The Primary Driver?

New Vehicle Deductibles

What Comprehensive Deductible Would You Like?

$250

$500

$1000

Decline Comprehensive Coverage

Comprehensive covers everything other than an at fault accident. Ex. Theft, vandalism, a rock cracking your windshield on the freeway, etc.

What Collision Deductible Would You Like?

$250

$500

$1000

Decline Collision Coverage

NOTE: The lower the deductible, the higher the premium.

Add/Remove Driver Information

Which driver action are you requesting?

Add a new driver to my policy

Remove a driver from my policy

New Driver Information

New Driver Full Name

New Driver Date of Birth

MM slash DD slash YYYY

New Driver DL#

New Driver's Relation To You

Other Relation

Does new driver live with you?

Yes

No

New Driver's Employer or School

Current High School Student With A 3.0 or Better GPA?

Yes

No

If the new driver is a high school student with a 3.0 or better GPA, they may qualify for a “good student discount”. You will need to submit proof (last report card).

New Driver's Address

Street Address Address Line 2 City State ZIP Code

Removed Driver Information

Name

First Last

Reason For Removing Driver

Is This Person Still A Household Resident?

Yes

No

Document Request

Which Document(s) Are You Requesting?

When Do You Need The Document(s)?

MM slash DD slash YYYY

If you need your documents urgently please click the link below and navigate to your insurance carrier’s website or service phone number.
If this is not a time-sensitive request our team will have your documents emailed to you in less than 24 business hours.

Other Change Details

Please Specify Your "Other" Changes. Be As Specific As Possible

Business Policy Changes

Business Name(Required)

Name of person submitting request(Required)

First Last

Email(Required)

Phone

Business Policy(ies) Needing Service

BOP

Business Auto/Fleet

Business Liability

Business Property

Cyber Liability

Excess Liability

General Liability

Workers Comp

Other

Other Type of Policy(Required)

Do you need to file a claim or request a COI?

File A Claim

Request A COI

Other Type of Change

Please explain the details of your change reqeust.

Please upload any files required to make the change.

Max. file size: 100 MB.

Claim Information

Date of Loss

MM slash DD slash YYYY

Details of the claim you would like to file.

Consent(Required)

I understand that the purpose of completing this form is to inform Shepherd Insurance Partners about a claim I would like to file. I also understand that completing this form does not constitute filing a claim with my insurance carrier.

Shepherd Insurance Partners will use this information to evalute my claim and advise me about filing a claim.

CL Intake

"*" indicates required fields

Business Details

Business Name:*

Business Entity:*

FEIN / Tax-ID Number:

Phone Number:*

Email:*

Mailing Address:*

Street Address City State ZIP Code

Is Physical Address Same As Mailing Address?*

Yes

No

Physical Address:*

Street Address City 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

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?

CL Renewal

"*" indicates required fields

Full Name:*

First Last

Business Legal Name (and DBA, if applicable):

Phone Number:*

Email Address:*

Mailing/Correspondence Address:*

Street Address Address Line 2 City State ZIP Code

Are there any significant changes in your business operation since we last spoke? (Merger/Acquisition, New lines of business, new categories of operation, etc.)

How many W-2 employees does your team currently have?

What is your projected total W-2 payroll for the upcoming 12 months?

What is your projected gross revenue for the upcoming 12 months?

What is your projected total paid to subcontractors or 1099 team members for the upcoming 12 months? (if applicable)

If you have acquired any new property, added locations, or made other changes that effect your insurance needs, please detail them here.

We maintain an extensive network of local professionals to help our clients with many potential needs. Please check any box below for any service you'd like a personal introduction to one of our Channel Partners in that area.

Health or Life Insurance Agent

Financial Advisor

C.P.A. or Accountant

Bookkeeping Service

Attorney (all categories)

Commercial Lender

Commercial Real Estate Agent Commercial Property Manager

Banker

Hard / Private Money Lender Mortgage lender

Residential Real Estate Agent Residential Property Manager

Roofer

Construction / Home Builder Handyman / Routine Housework Automobile Sales

Automobile Service / Repair

Moving Company

Landscaper

Electrician

Plumber

Heating and A/C Service / Repair

Pool Service / Repair

Pest Control / Exterminator

Marketing agency

Physician (All Specialties)

Dentist

Chirocractor

Physical Therapist

Computer Service / Repair

Web Design / SEO Consulting

Do your renewal policies need to be submitted to L&I?

Do we need to add any additional insured's to your policy? (Bank, landlord, new contracts, etc)

My business is built on referrals. What businessowners do you know that could benefit from my help?

Is there anything else that we need to know now to make sure your insurance program is exactly what you need?

You may upload up to 3 files to us, if necessary.

Drop files here or

Max. file size: 100 MB, Max. files: 3.

PL Intake

Step 1 of 16

6%

Primary Insured Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Drivers License(Required)

*Required for all vehicle insurance quotes

Date of Birth(Required)

MM slash DD slash YYYY

Marital Status

Single

Married

Divorced

Widowed

Education

High School

Associate Degree

Bachelor’s Degree

Graduate or Professional Degree

Some College

Spouse Information

Spouse Name(Required)

First Last

Spouse Birth Date(Required)

MM slash DD slash YYYY

Spouse Drivers License(Required)

*Required for all vehicle insurance quotes

Spouse Education

High School

Associate Degree

Bachelor’s Degree

Graduate or Professional Degree

Some College

How did you hear about Watts Insurance Group?

Client Referral

Mortgage Referral

Realtor Referral

Financial Advisor Referral

Other Referral

Facebook

Google

Instagram

Other

Referred By Name

First Last

What type of insurance can we quote for you?(Required)

Auto

Home

Condo

Umbrella

Investment Property

Motorcycle/Slingshot/ATV

Golf Cart

Boat

RV

Renters

Other

What other type of insurance can we quote for you?

New purchase or already own the condo/home?

New Purchase

Already Own

How do you use the condo/home?

Primary Residence

Secondary Residence

Rental

Current Address (No PO Boxes)(Required)

Street Address Address Line 2 City State ZIP Code

Address of Property Being Purchased(Required)

Same as current address

Street Address Address Line 2 City State ZIP Code

Would you like to add a different mailing address?(Required)

Yes

No

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Renters Insurance

What type of property are you renting?

Please explain

Community Name

Does landlord/management require proof of insurance?

What floor is your apartment located on?

How many residents live there full-time?

Dog(s)?(Required)

Yes

No

Dog Breeds

If mixed please indicate type of mix.

Home Information

Swimming Pool(Required)

Yes

No

Swimming Pool Enclosed/Fenced?(Required)

Yes

No

Diving Board or Slide?(Required)

Yes

No

Trampoline(Required)

Yes

No

Dog(s)?(Required)

Yes

No

Dog Breeds

If mixed please indicate type of mix.

Any bite history or security training?(Required)

Yes

No

Home Information Continued

Year Roof Updated(Required)

Year Furance Updated

Closing Date (If New Purchase)

MM slash DD slash YYYY

Home Notes/Scheduled Property

Auto Information

Total Drivers in Home(Required)

1

2

3

4

5

Total Vehicles in Home(Required)

1

2

3

4

5

Rental Reimbursement

Yes

No

Roadside Service

Yes

No

Full Glass Coverage

Yes

No

Do you want to participate in Driving app to save up to 10%?

Yes

No

Spouse information will automatically be used for Driver #2

Driver #2

Name

First Last

Phone

Email

Date of Birth

MM slash DD slash YYYY

Drivers License

Occupation

Relationship to you

Spouse

Child

Parent

Other

Additional Discounts

Drivers Ed

Good Student 3.0 GPA

Driver #3

Name

First Last

Phone

Email

Date of Birth

MM slash DD slash YYYY

Drivers License

Occupation

Relationship to you

Spouse

Child

Parent

Other

Additional Discounts

Drivers Ed

Good Student 3.0 GPA

Driver #4

Name

First Last

Phone

Email

Date of Birth

MM slash DD slash YYYY

Drivers License

Occupation

Relationship to you

Spouse

Child

Parent

Other

Additional Discounts

Drivers Ed

Good Student 3.0 GPA

Driver #5

Name

First Last

Phone

Email

Date of Birth

MM slash DD slash YYYY

Drivers License

Occupation

Relationship to you

Spouse

Child

Parent

Other

Additional Discounts

Drivers Ed

Good Student 3.0 GPA

Vehicle #1

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

No

Rideshare or Delivery

Yes

No

Collision Deductible

Decline Collision

$250

$500

$1,000

Comprehensive Deductible

Decline Comp

$250

$500

$1,000

Vehicle #2

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

No

Rideshare or Delivery

Yes

No

Comprehensive Deductible

Decline Comp

$250

$500

$1,000

Collision Deductible

Decline Collision

$250

$500

$1,000

Vehicle #3

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

No

Rideshare or Delivery

Yes

No

Comprehensive Deductible

Decline Comp

$250

$500

$1,000

Collision Deductible

Decline Collision

$250

$500

$1,000

Vehicle #4

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

No

Rideshare or Delivery

Yes

No

Comprehensive Deductible

No Comp

$250

$500

$1,000

Collision Deductible

No Collision

$250

$500

$1,000

Vehicle #5

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

No

Rideshare or Delivery

Yes

No

Comprehensive Deductible

No Comp

$250

$500

$1,000

Collison Deductible

No Collision

$250

$500

$1,000

Investment Property

Address(Required)

Street Address Address Line 2 City 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

First Last

Vehicle Type(Required)

Motorcycle

Slingshot

ATV

Current Motorcycle License

Yes

No

Has Driver Completed Safety Course?

Yes

No

Year

Make

Model

Value of Vehicle New

CC's

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.

Umbrella Coverage Amount

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

Do you own a boat trailer?

Yes

No

Golf Cart

Year

Make

Model

VIN or S/N

Primary Use

Transportation

Golfing

Fuel Type

Electric

Gas

Recreational Vehicle

RV Type

5th Wheel

Motorcoach

Other

Agreed Value ($)

Year

Make

Model

Do you own any of the following items?

Boat/Yacht

Motorcycle

ATV

RV

Golf Cart

Vacant Land

Business

Rental Property

Classic Vehicle

Please upload current policy documents if you have them available.

Max. file size: 100 MB.

Consent(Required)

Shepherd Insurance Partners may contact me via phone call, email and text message.

I agree to the Shepherd Insurance Partners privacy policy.
https://shepherdinsurancepartners.com/privacy-policy/

CAPTCHA

PL Renewal

Step 1 of 12

8%

Name(Required)

First Last

Email(Required)

Are you driving for a rideshare or delivery company?(Required)

Yes

No

If yes what company?(Required)

Have you started using your vehicle for business?

Yes

No

(Roofing, real estate, advertisement, etc.)

What Business?

Please check all situations that apply to you.(Required)

Address Change

Birth of a child

Career Change

Driver Added

Driver Removed

Home renovations/improvments

Marital Status

Purchased ATV/Motorcycle/Slingshot

Purchased Boat

Purchased Home/Rental Property/Second Home

Started A Business

Vehicle Bought

Vehicle Sold

No Changes

Date You Moved

MM slash DD slash YYYY

Updated Address

Street Address Address Line 2 City State ZIP Code

Name

Birthday

Congrats on the new career! What is your new job title?(Required)

Add Driver To Policy

First Last

Birthday

Relationship to You

DL #

Remove Driver From Policy

First Last

What is your current marital status?

Married

Divorced

Widowed

Spouse Name

What new toy(s) did you purchase?

ATV

Boat

Golf Cart

Motorcycle

Slingshot

List make, model and estimated purchase price for each new toy.

Year

Make

Model

Click the + to add more rows.

What type of property did you purchase?(Required)

Primary Home

Rental Home/Investment Property

Second Home/Vacation Home

Date Purchased

MM slash DD slash YYYY

New Property Address(Required)

Street Address Address Line 2 City State ZIP Code

Is the Property currently insured? With who?

What is the name of your new business?

What is the industry of your new business?

Is your business currently insured?

Yes

No

Date Purchased

MM slash DD slash YYYY

Year/Make/Model of purchased vehicle(s)

Year

Make

Model

Click the + to add rows for additional vehicles.

Date Sold

MM slash DD slash YYYY

Year/Make/Model of sold vehicle(s)

Year

Make

Model

Click the + to add rows for additional vehicles.

Please list the renovations and an approximate cost of each.

You can use the + button on the right side to add additional rows.

Are there any additional changes that we should know about prior to your insurance renewal?

Name

This field is for validation purposes and should be left unchanged.