New Prospect Intake Form Step 1 of 22 4% Assigned AdvisorAmelia D'AngeloBecky LohrCindy RudinskyConnie FauvieElizabeth MoranEllie PlattGriffin LoughKate GuesmanKristy JohnsonRosalie VanCampHow did you hear about us?AAA InsuranceAAA Prior CustCarrier DirectCross-SellCurrent CustomerCustomer ReferCustomer ReferralDavis LawExtra Mile WebsiteFacebookFamilyFRMS- Gordon, TGold StarGold StarGoogle/Search EngineIAOAIns Agnt-UnknownInstagramLinkedInMtg-1st UnitedMtg-ArvestMtg-Flat BrnchMtg-GatewayMtg-Nw Am FundMtg-Pro MtgMtg-UFFCMtg-UFFC-TahlMtg-unknownMtg-ZfgNetwking eventNetworkingOLT-B. ParkerPersonal FrndProfessional ReferralRealtorRemarketRewriteRltr- OtherRltr-Chin&CohnRltr-Cnt21Rltr-Coldw BnkRltr-EXPRltr-Klr WlmsSF-BillingsSF-Bryan SmithSF-S. LaneSF-T.BledsoeWalk-inWinbackWho Referred You? 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 Name(Required) First Last Phone(Required)Email(Required) Date of Birth MM slash DD slash YYYY Drivers License SSN Occupation Marital Status Single Married Divorced Widowed Spouse InformationSpouse will be considered driver #2 if quoting auto.Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY SSNPhone Current Address (location of home to be insured) 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 Mailing address different than location address? Yes No Mailing 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 Years at current address0-2 Years2-5 Years5+ YearsPrior 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 Purchase Date/Closing Date MM slash DD slash YYYY Property TypeSingle FamilyMulti FamilyCondoFarm/RanchMobile HomeVacant LandYear Home Was BuiltFoundationBasementCrawlspaceSlabSq FtFrame DetailVinylMetalHardiplankWoodBrick VeneerStone VeneerFinished Basement %# of stories 1 1.5 2 Bathrooms11.522.533.544.5Roof MaterialComposite ShinglesAsphalt ShinglesArchitectural ShinglesMetalTileRoof ShapeHipGableFlatYear Roof UpdatedAny updates to heating, electrical or plumbing? Heating Electrical Plumbing Year Heating UpdatedType of Update Full Replacement Partial Update Year Electrical UpdatedType of Update Full Replacement Partial Update Year Plumbing Updated?Type of Update Full Replacement Partial Update Garage Yes Attached Yes Detached None Garage 1 Car 2 Car 3 Car 4 Car Detached Structures Yes No Detatched StructureWhat Type?GarageShopShedBarnPool HouseOtherWhat Type?(Required) Detached Structure Sq. Footage Detatched Building ExteriorWoodMetalVinylOtherOther Exterior Material Detatched Roof TypeAsphalt ShingleMetalOtherOther Roof Type(Required) Detatched Building Roof AgeDetached Structures Used For Farming Purposes? Yes No Which building and how is it used?(Required) More than 5 acres? Yes No Fireplace Yes - Gas Yes - Wood No Woodstove Yes No Deck/Patio Yes - Covered Yes - Screened Yes - Enclosed No Sq. FootageSwimming Pool Yes No Swimming Pool Fenced and Locked? Yes No Diving Board or Slide? Yes No Trampoline Yes No Trampoline Has A Net? Yes No Monitored Burglar/Fire Alarm? Yes No Alarm Company Responding Fire Department? Miles to Fire Department?Paid Fire Subscription Required? Yes No Unknown Fire Protection Class Any Pets? Cat Dog Cat & Dog Other Dog Breeds Add RemoveIf mixed please indicate type of mix.Any bite history or security training? Yes No Any Horses? Yes No How Many?Any Cattle? Yes No How Many?Any Other Livestock? Yes No Types of LivestockLivestockHow Many Add RemoveFarming Operations? Yes No Scheduled Personal Property Jewelry Furs Firearms Art Cameras Musical Instruments Other Total Value of Jewelry Owned?Total Value of Firearms Owned?Total Value of Art/Cameras/Furs/Musical Instruments Owned?Valuable Items List (Click the + to add additional items) Add RemovePlease list each item and include an appraised/estimated value. Only one item per row please.Home NotesFarmingFarming Type Annual Farming IncomeCurrent Carrier InformationCurrent Carrier Policy Expiration MM slash DD slash YYYY Dwelling LimitPersonal Property LimitLiability LimitDeductibleCurrent PremiumEscrowed Yes No Mortgage Company Have there been any home claims in the last 5 years? Yes No Claims Add RemoveInclude Date of claim, Type of claim (wind/hail/water/lightning/other), Amount paid. Total Drivers in Home 1 2 3 4 5 Total Vehicles in Home 1 2 3 4 5 Med PayVehicle #1Vehicle Year Make Model VIN Comprehensive Deductible $500 $1,000 Decline Comp Collision Deductible $500 $1,000 Decline Comp Business Use Yes No Rideshare or Delivery?(Required) Yes No Roadside Yes No Rental Reimbursement Yes No Vehicle #2Vehicle Year Vehicle Make Vehicle Model VIN Comprehensive Deductible $500 $1,000 Decline Comp Collision Deductible $500 $1,000 Decline Comp Business Use(Required) Yes No Rideshare or Delivery(Required) Yes No Roadside Yes No Rental Reimbursement Yes No Vehicle #3Vehicle Year Vehicle Make Vehicle Model VIN Business Use Yes No Rideshare or Delivery(Required) Yes No Rental Reimbursement Yes No Rental Reimbursement $30/Day $50/Day Comprehensive Deductible $500 $1,000 Decline Comp Collision Deductible $500 $1,000 Decline Comp Vehicle #4Vehicle Year Vehicle Make Vehicle Model VIN Business Use Yes No Rideshare or Delivery(Required) Yes No Rental Reimbursement Yes No Rental Reimbursement $30/Day $50/Day Comprehensive Deductible $500 $1,000 Decline Comp Collision Deductible $500 $1,000 Decline Comp Vehicle #5Vehicle Year Vehicle Make Vehicle Model VIN Business Use Yes No Rideshare or Delivery(Required) Yes No Rental Reimbursement Yes No Rental Reimbursement $30/Day $50/Day Comprehensive Deductible $500 $1,000 Decline Comp Collison Deductible $500 $1,000 Decline Comp Driver #2Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY SSNDrivers License Relationship to you(Required) Spouse Child Parent Other Occupation Any tickets or accidents in the last 5 years?DateDescription Add Remove Driver #3Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY SSNDrivers License Relationship to you(Required) Spouse Child Parent Other Occupation Any tickets or accidents in the last 5 years?DateDescription Add Remove Driver #4Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY SSNDrivers License Relationship to you(Required) Spouse Child Parent Other Occupation Any tickets or accidents in the last 5 years?DateDescription Add Remove Driver #5Name(Required) First Last PhoneEmail Date of Birth(Required) MM slash DD slash YYYY SSNDrivers License Relationship to you(Required) Spouse Child Parent Other Occupation Any tickets or accidents in the last 5 years?DateDescription Add Remove Current Auto Policy InformationLiability Limits $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 $500,000/$500,000/$500,000 UM/UIM $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 Decline Current Auto Insurer Name First Last Current Policy Expiration Date MM slash DD slash YYYY Length of Time with Current Auto Insurer Current Towing Limit? Current Rental Car Reimbursement Limit? Current Monthly Auto Premium Pay Plan PreferredFull Pay2 Pay4 PayMonthly Dwelling Fire PolicyAddress(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 Property Status(Required) Currently Occupied with Tenants Listed For Sale - No Occupants Listed For Rent - No Occupants Undergoing Renovations - Vacant Untitled First Choice Second Choice Third Choice Motorcycle/ATVName of Primary Driver(Required) First Last Vehicle Type(Required) Motorcycle Slingshot ATV Is Vehicle Used for Racing?(Required) Yes No Current Motorcycle License Yes No Has Driver Completed Safety Course? Yes No Year Make Model VIN 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.(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?(Required)This includes primary, secondary, vacation, rental and investment properties.How many home/renters claims have you made in the last 5 years?(Required)How many vehicles do you own?(Required)Do you own any of the following items?(Required) Boat/Yacht Motorcycle ATV Golf Cart Vacant Land Business Boat InformationWhere is boat stored? Primary Residence Marina - Slip Other Year Make Model Hull Number Motor Type Inboard Outboard Top Speed (MPH)Boat LengthBoat is used for racing? Yes No Do you own a boat trailer? Yes No Golf CartYear Make Model Primary Use Transportation Golfing Fuel Type Electric Gas Recreational VehicleRV Type 5th Wheel Motorcoach Other Year Make Model Please upload current policy documents if you have them available.Max. file size: 98 MB.Consent(Required) Platt Insurance may contact me via phone call, email and text message.I agree to the Platt Insurance privacy policy and I give Platt Insurance permission to contact me by phone, email and text message.
