Private Client - New Customer Discovery

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Primary Insured

First Name *

Last Name *

Street *

City *

State / Province *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Date of Birth *

Occupation *

Driver License Number *

Spouse Information

Name (First and Last) *

Date of Birth *

Occupation *

E-Mail Address *

Phone Number

Driver License Number *

Child(ren) Information

Do you have children at home who drive?

Yes
No

If yes, please provide the following for each child: Name; DOB; Driver License #

Home Information

Address, including City/State/Zip Code

What type of property is the above address?

Main Home
Secondary Home
Rental Property
Condo
Townhome

Current Insurance Carrier

Current Insurance Premium

Year Home was Built

Purchase Date

Dwelling Coverage Amount

Square Footage

Number of Bedrooms

Number of Bathrooms

Number of Stories

Foundation Type

Siding Type

Number of Car Garaged

Roof Type

Year Roof Put On

Year HVAC replaced

Year Plumbing Replaced

Year Electrical Replaced

Alarm System

Yes
Fire
Burglary
Both
No

Do you have Pets?

Yes
No

If yes, please provide breed type(s).

Do you have a Swimming Pool?

Yes
No

Do you have a Trampoline?

Yes
No

Do you have Solar Panels?

Yes
No

If yes, please provide the number of panels and total value.

Do you have a Water Monitoring System with Alarm?

Yes
No

Do you have a Gas Leakage Detection System?

Yes
No

Do you have a Fire Sprinkler System?

Yes
No

If yes, is it a full or partial system?

Do you have a Whole House Backup Generator?

Yes
No

Number of live-in staff

Number of Skylights

Do you live in a Gated Community?

Yes
No

Do you have Lightning Protection?

Yes
No

New Purchase Home

Purchase Price

Loan Amount

Estimated Closing Date

Lender/Realtor Contact Information

Condo/Townhome Information

Deductible for Condo Association policy

Dwelling Coverage needed

Content Coverage needed

Rental Property Information

Rental Basis

Property Management Company

Renter's Insurance Required for Tenant

Are you listing this rental on:

Airbnb
VRBO
Other

Automobile Information

Current Insurance Carrier

Current Insurance Premium

Effective Date of Coverage

List Name(s) of Drivers to be Rated

Identify the YEAR, MAKE, MODEL, and VIN for each car to be insured

Liability Limits

Uninsured/Underinsured Motorist Limits

Personal Injury Protection (PIP) Limits

Medical Limits

Comprehensive Deductible

Collision Deductible

Roadside Assistance

Rental Reimbursement

Is GAP coverage needed?

Yes
No

Will any driver work for Uber/Lyft?

Yes
No

Are there any claims within the last 5 years?

Yes
No

Any Driving Tickets in the last 3 years?

Yes
No

Umbrella

Amount Needed to Protect Assets

Liability Limit Needed

Uninsured/Underinsured Limits Needed

Personal Property Information

Number of personal residences insured under Homeowner's policy or dwelling form

Number of rental insured under Homeowner's policy or dwelling form

Number of acres - Rural vacant land

Number of acres - Urban vacant land

Personal Automobiles Information

What is the current liability limits on you existing auto policy?

Number of autos you maintain

Number of motorcycles you maintain

Number of drivers

Number of drivers over 89 years

Number of drivers with a major violation within last 5 years

Watercraft/Unlicensed Vehicles/Jet Skis

What are the current liability limits on your existing policy

Number of boats under 27 feet and under 45 MPH

Number of boats over 27 feet with max speed 45 MPH (yachts, sailboats)

Number of boats under 42 feet and between 45-60 MPH

Number of golf carts

Number of jet skis with speed under 55 MPH

Number of ATVs, snowmobiles, Mules

Business Property

Number of Habitational Units

Number of Swimming Pools

Square Feet of Professional & Service Offices

Business Automobiles

Number of private passenger autos

Number of pickups 1/2 ton to 1 ton

Number of non-owned autos

Number of drivers with a major violation within last 5 years

Boat Information

VIN

Make

Model

Year

Length

Licensed

Horsepower

Max Speed

Value of Boat

Value of Motor

Location Where Stored

Number of boating years for each driver

Security of Storage

Boat Trailer Information - Complete if you want your Trailer Insured

Year

Make

Model

VIN

Value you want insured

High Value Items - Jewelry

Do you want blanket or itemized coverage?

Provide jewelry Description, Value and Date of Appraisal

High Value Items - Fine Art

Do you want blanket or itemized coverage?

Provide fine art Description, Value and Date of Appraisal

High Value Items - Furs

Do you want blanket or itemized coverage?

Provide fur Description, Value and Date of Appraisal

High Value Items - Collectibles

Do you want blanket or itemized coverage?

Provide collectible Description, Value and Date of Appraisal

High Value Items - Storage Information

For the above identified High Value Items, where are they stored?

Is there a monitored burglary system?

Yes
No

Are the High Value Items kept in a safe?

Yes
No

Flood Information

Flood Zone

Is there an elevation certificate available?

Yes
No

Dwelling Coverage Amount

Contents Coverage Amount Needed

Is Coverage already in place?

Yes
No

Is this coverage required by your mortgage company?

Yes
No

Earthquake

Amount of Coverage Desired

Desired Deductible Percentage

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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