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Home > Homeowners > Private Client - New Customer Discovery
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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?

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?




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




Do you have Pets?

If yes, please provide breed type(s).
Do you have a Swimming Pool?

Do you have a Trampoline?

Do you have Solar Panels?

If yes, please provide the number of panels and total value.
Do you have a Water Monitoring System with Alarm?

Do you have a Gas Leakage Detection System?

Do you have a Fire Sprinkler System?

If yes, is it a full or partial system?
Do you have a Whole House Backup Generator?

Number of live-in staff
Number of Skylights
Do you live in a Gated Community?

Do you have Lightning Protection?

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:


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?

Will any driver work for Uber/Lyft?

Are there any claims within the last 5 years?

Any Driving Tickets in the last 3 years?

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?

Are the High Value Items kept in a safe?

Flood Information
Flood Zone
Is there an elevation certificate available?

Dwelling Coverage Amount
Contents Coverage Amount Needed
Is Coverage already in place?

Is this coverage required by your mortgage company?

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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