FORMS
PL Intake
CL Intake
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
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
What type of property are you renting?
Single Family Home
Multi-Family Home (Duplex, etc.)
Apartment
Other
Please explain
Community Name
Does landlord/management require proof of insurance?
Yes
No
What floor is your apartment located on?
First Floor
Second Floor
Third Floor or Above
How many residents live there full-time?
1
2
3
4+
Dog(s)?
(Required)
Yes
No
Dog Breeds
Add
Remove
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
Add
Remove
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
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
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
$1,000,000
$2,000,000
$5,000,000
I'm not sure – Please help
Boat Information
Where is boat stored?
Primary Residence
Marina – Slip
Marina – Dry Stack
Other
Year
Make
Model
Hull Number
Motor Type
Inboard
Outboard
Top Speed (MPH)
Boat Length
Do you own a boat trailer?
Yes
No
Golf Cart
Year
Make
Model
VIN or S/N
Primary Use
Transportation
Golfing
Fuel Type
Electric
Gas
Recreational Vehicle
RV Type
5th Wheel
Motorcoach
Other
Agreed Value ($)
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)
Smith Insurance Group may contact me via phone call, email and text message.
I agree to the Watts Insurance Group privacy policy. https://www.wattsinsurancegroup.com/privacy/
CAPTCHA
CL Intake
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
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