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(903)868-1200
Intake
Intake
cindymc
2021-11-29T17:23:40+00:00
Step
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8
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Prospect Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
SSN
(Required)
Drivers License
(Required)
Occupation
(Required)
Policies Being Quoted
(Required)
Auto
Home
Referred By Name
First
Last
Assigned Agent
Cindy McCullough
Stephanie Cotton
Robin Pierson
Kay Mayfield
Danna Humphrey
Lisa Smith
Hidden
Date
MM slash DD slash YYYY
Home Information
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
Year Home Was Built
(Required)
Purchase Date
MM slash DD slash YYYY
Sq Ft
(Required)
# of Stories
1
1.5
2
# of Bedrooms
1
2
3
4
5
6
Bathrooms
1
1.5
2
2.5
3
3.5
4
4.5
Garage
No Garage
1
2
3
4
Number of Residents
(Required)
Additional Structures
Yes
No
Additional Structures Info
Please describe the additional structures on your property.
More than 5 acres?
(Required)
Yes
No
Fireplace?
(Required)
Yes
No
Swimming Pool?
(Required)
Yes
No
Swimming Pool Fenced?
(Required)
Yes
No
Diving Board/Slide?
(Required)
Yes
No
Gated Community?
(Required)
Yes
No
Monitored Alarm?
(Required)
Yes
No
Dog(s)?
(Required)
Yes
No
Dog Breeds
(Required)
Add
Remove
Solar Panels?
Yes
No
How Many Solar Panels?
Add
Remove
Exterior Material
(Required)
Brick Veneer
Clapboard
Vinyl Siding
Stone Veneer
Stucco
Year Roof Updated
(Required)
Year Electrical Updated
Year Plumbing Updated?
Year HVAC Updated
Home Coverage Limits
Dwelling
Loss of Use
Wind/Hail Deductible
All Other Perils Deductible
Other Structures
Liability
Loan Amount
Personal Property
Medical Payments
Scheduled Personal Property
Artwork
Collectibles
Firearms
Jewelry
Technology
Other
Valuable Items List (Click the + to add additional items)
Add
Remove
Please list each item and include an appraised/estimated value. Only one item per row please.
Home Notes
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
Comprehensive Deductible
(Required)
$100
$250
$500
$1,000
No Coverage
Collision Deductible
(Required)
$100
$250
$500
$1,000
No Coverage
Rental Reimbursement?
(Required)
Yes
No
Roadside?
(Required)
Yes
No
PIP/Medical Payments
(Required)
PIP
Medical Payments
Decline Both
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
Vehicle Year
(Required)
Make
(Required)
Model
(Required)
VIN
Business Use
(Required)
Yes
No
Rideshare and/or Delivery
(Required)
Yes
No
Total Drivers In Home
(Required)
1
2
3
4
5
Total Vehicles In Home
(Required)
1
2
3
4
5
Driver #2 Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Drivers License
(Required)
Occupation
Has A Primary Vehicle
Yes
No
Vehicle #2 Information
Vehicle Year
(Required)
Vehicle Make
(Required)
Vehicle Model
(Required)
VIN
Comprehensive Deductible
(Required)
$100
$250
$500
$1,000
Decline Comp
Collision Deductible
(Required)
$100
$250
$500
$1,000
Decline Comp
Business Use
(Required)
Yes
No
Rideshare and/or Delivery
(Required)
Yes
No
Driver #3 Name
First
Last
Phone
Email
Date of Birth
MM slash DD slash YYYY
Drivers License
Occupation
Has A Primary Vehicle 3
Yes
No
Vehicle #3 Information
Vehicle Year
Vehicle Make
Vehicle Model
VIN
Comprehensive Deductible
$100
$250
$500
$1,000
Decline Comp
Collision Deductible
$100
$250
$500
$1,000
Decline Comp
Business Use
Yes
No
Rideshare and/or Delivery
Yes
No
Driver #4 Name
First
Last
Phone
Email
Date of Birth
MM slash DD slash YYYY
Drivers License
Occupation
Has A Primary Vehicle 4
Yes
No
Vehicle #4 Information
Vehicle Year
Vehicle Make
Vehicle Model
VIN
Comprehensive Deductible
$100
$250
$500
$1,000
Decline Comp
Collision Deductible
$100
$250
$500
$1,000
Decline Comp
Business Use
Yes
No
Rideshare and/or Delivery
Yes
No
Driver #5 Name
First
Last
Phone
Email
Date of Birth
MM slash DD slash YYYY
Drivers License
Occupation
Has A Primary Vehicle 5
Yes
No
Vehicle #5 Information
Vehicle Year
Vehicle Make
Vehicle Model
VIN
Collision Deductible
$100
$250
$500
$1,000
Decline Comp
Comprehensive Deductible
$100
$250
$500
$1,000
Decline Comp
Business Use
Yes
No
Rideshare and/or Delivery
Yes
No
What other types of insurable property do you own?
Motorcycle
ATV
Golf Cart
Boat
Vacation Home
Investment Property
Plane
This is important information for us to make sure you're covered properly (even if some of these items are insured with another agency)
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