031 - Personal Lines Intake Form - INTERNAL USE ONLY • iProtect Insurance & Financial Services

Personal Lines Intake Form

What's your name?*

First Last

What is your date of birth?*

How did you hear about iProtect?*

Referred by someone

Google / Online Search

Facebook

Received phone calls from iProtect

Received emails from iProtect

Received mailings from iProtect

Other

Who referred you to iProtect?*

Cell Phone Number*

Text Message authorization*

Yes

Email*

What's your current address?*

Street Address City State ZIP Code

Have you moved in the past 5 years?

Yes

Enter your previous address*

Street Address City State ZIP Code

Assigned Agent*

Jessecca Miller

Bruce Payne

Athena Stevens

Justin Miller

Hidden

Jess - Cell Number

Hidden

Justin - Cell Number

Hidden

Bruce - Cell Number

Hidden

Athena - Cell Number

What's your relationship status?*

Single

Married

Spouse's Name*

First Middle Last

Your Spouse's Date of Birth?*

Spouse's Cell Phone Number

Text Message authorization

Yes

Spouse's Email

Line(s) of Business*

AUTO

Desired Policy Effective Date:

Driver's License Number*

Select state*

Spouse's Driver's License Number*

Select state*

Number of Additional Household Drivers:*

Add'l Driver 1*

First Last

Add'l Driver 1 - DOB*

Add'l Driver 1 - DL #*

Add'l Driver 1 DL State*

Add'l Driver 2*

First Last

Add'l Driver 2 - DOB*

Add'l Driver 2 - DL #*

Add'l Driver 2 DL State*

Add'l Driver 3*

First Last

Add'l Driver 3 - DOB*

Add'l Driver 3 - DL #*

Add'l Driver 3 DL State*

Add'l Driver 4*

First Last

Add'l Driver 4 - DOB*

Add'l Driver 4 - DL #*

Add'l Driver 4 DL State*

Add'l Driver 5*

First Last

Add'l Driver 5 - DOB*

Add'l Driver 5 - DL #*

Add'l Driver 5 DL State*

Add'l Driver 6*

First Last

Add'l Driver 6 - DOB*

Add'l Driver 6 - DL #*

Add'l Driver 6 DL State*

Do you currently have Auto Insurance?*

Yes

Current Insurance Company Name

Current Policy Expiration Date

Number of Vehicles*

Vehicle 1 - Year*

Vehicle 1 - Make*

Vehicle 1 - Model*

Vehicle 1 - VIN

Is Vehicle 1 financed?*

Vehicle 1 - Finance company name:*

Vehicle 1 - Comprehensive Coverage Deductible:*

Vehicle 1 - Collision Coverage Deductible:*

Vehicle 2 - Year*

Vehicle 2 - Make*

Vehicle 2 - Model*

Vehicle 2 - VIN

Is Vehicle 2 financed?*

Vehicle 2 - Finance company name:*

Vehicle 2 - Comprehensive Coverage Deductible:*

Vehicle 2 - Collision Coverage Deductible:*

Vehicle 3 - Year*

Vehicle 3 - Make*

Vehicle 3 - Model*

Vehicle 3 - VIN

Is Vehicle 3 financed?*

Vehicle 3 - Finance company name:*

Vehicle 3 - Comprehensive Coverage Deductible:*

Vehicle 3 - Collision Coverage Deductible:*

Vehicle 4 - Year*

Vehicle 4 - Make*

Vehicle 4 - Model*

Vehicle 4 - VIN

Is Vehicle 4 financed?*

Vehicle 4 - Finance company name:*

Vehicle 4 - Comprehensive Coverage Deductible:*

Vehicle 4 - Collision Coverage Deductible:*

Vehicle 5 - Year*

Vehicle 5 - Make*

Vehicle 5 - Model*

Vehicle 5 - VIN

Is Vehicle 5 financed?*

Vehicle 5 - Finance company name:*

Vehicle 5 - Comprehensive Coverage Deductible:*

Vehicle 5 - Collision Coverage Deductible:*

Vehicle 6 - Year*

Vehicle 6 - Make*

Vehicle 6 - Model*

Vehicle 6 - VIN

Is Vehicle 6 financed?*

Vehicle 6 - Finance company name:*

Vehicle 6 - Comprehensive Coverage Deductible:*

Vehicle 6 - Collision Coverage Deductible:*

Vehicle 7 - Year*

Vehicle 7 - Make*

Vehicle 7 - Model*

Vehicle 7 - VIN

Is Vehicle 7 financed?*

Vehicle 7 - Finance company name:*

Vehicle 7 - Comprehensive Coverage Deductible:*

Vehicle 7 - Collision Coverage Deductible:*

Vehicle 8 - Year*

Vehicle 8 - Make*

Vehicle 8 - Model*

Vehicle 8 - VIN

Is Vehicle 8 financed?*

Vehicle 8 - Finance company name:*

Vehicle 8 - Comprehensive Coverage Deductible:*

Vehicle 8 - Collision Coverage Deductible:*

Would you like to enroll in telematics?*

Additional Information:

HOME

Desired Home Policy Effective Date:

Is this for a new home purchase?*

Is there a mortgagee / lienholder?*

Mortgagee / Lienholder Name:*

Escrow bill?*

Is the property address the same as the previously entered address?*

Yes

Property Address*

Street Address City State ZIP Code

Dwelling Usage:*

Primary Residence

Secondary Residence

Seasonal Residence

Year Built:*

Foundation Type:*

% of Basement Finished:*

Specify Foundation Type:*

Home Square Footage:*

Stories (not incl basement)*

Exterior Wall Material (select all that apply)*

Brick

Stone

Vinyl Siding

Aluminum Siding

Cement Fiber Siding

Wood Siding

Log

Stucco

OTHER

Specify Exterior Wall Material*

Roof Material*

Year of last Roof Update:*

Specify Roof Material:*

Number of Full Bathrooms:*

Number of Half Bathrooms:*

Primary Heat Type:*

Is there a swimming pool on the premises?*

Is the swimming pool fenced with a locking gate?*

Does the swimming pool have a diving board or slide(s)?*

Is there a trampoline on premises?*

Is the trampoline fenced?*

Please select all security devices present at the property location:*

Deadbolt Locks

Local Smoke Alarm

Fire Extinguisher

Smart Alarm System

Monitored Alarm System

Desired Dwelling Coverage Amount:

Desired Policy Deductible:*

Specify Desired Deductible:*

Additional Home Information:

RENTERS

Type of Rental Dwelling*

Single Family Residence

Apartment Complex

Duplex

Quadplex

Other

Name of Apartment Complex*

Amount of Personal Property Coverage*

Desired Amount of Coverage*

Amount of Liability Coverage*

Additional Details:

LANDLORD DWELLING

Desired Policy Effective Date:

Is this for a new purchase?*

Is there a mortgagee / lienholder?*

Mortgagee / Lienholder Name:*

Escrow bill?*

Property Address*

Street Address City State ZIP Code

Year Built:*

Foundation Type:*

Specify Foundation Type:*

% of Basement Finished:*

Home Square Footage:*

Number of Stories (not incl basement):*

Year of last Roof Update:*

LD - Exterior Wall Material (select all that apply)*

Brick

Stone

Vinyl Siding

Aluminum Siding

Cement Fiber Siding

Wood Siding

Log

Stucco

OTHER

Specify Exterior Wall Material*

Roof Material*

Specify Roof Material:*

Number of Full Bathrooms:*

Number of Half Bathrooms:*

Primary Heat Type:*

Is there a swimming pool on the premises?*

Is the swimming pool fenced with a locking gate?*

Does the swimming pool have a diving board or slide(s)?*

Is there a trampoline on premises?*

Is the trampoline fenced?*

Please select all security devices present at the property location:*

Deadbolt Locks

Local Smoke Alarm

Fire Extinguisher

Smart Alarm System

Monitored Alarm System

Desired Dwelling Coverage Amount:

Desired Policy Deductible:*

Specify Desired Deductible:*

Additional Details:

MOBILE / MANUFACTURED HOME

Desired Home Policy Effective Date:

Is this for a new home purchase?*

MH - Is there a mortgagee / lienholder?*

Mortgagee / Lienholder Name:*

Escrow bill?*

MH - Is the property address the same as the previously entered address?*

Yes

Property Address*

Street Address City State ZIP Code

Dwelling Usage:*

Primary Residence

Secondary Residence

Seasonal Residence

Rental / Landlord

In an approved park?*

Yes

Park Name*

Model Year*

Width (ft.)*

Length*

Tied Down?*

Yes

Exterior Wall Material*

Vinyl Siding

Aluminum Siding

Wood Siding

Other

Roof Material*

Asphalt Shingles

Metal

Other

Year of Last Roof Replacement*

Number of Full Bathrooms:*

Number of Half Bathrooms:*

Primary Heat Type:*

Is there a swimming pool on the premises?*

Is the swimming pool fenced with a locking gate?*

Does the swimming pool have a diving board or slide(s)?*

Is there a trampoline on premises?*

Is the trampoline fenced?*

Please select all security devices present at the property location:*

Deadbolt Locks

Local Smoke Alarm

Fire Extinguisher

Smart Alarm System

Monitored Alarm System

Skirting around foundation?

Yes

Desired Dwelling Coverage Amount*

Desired Policy Deductible*

$500

$1,000

$2,500

Other

Additional Details:

MOTORCYCLE / ATV

Type of Vehicle(s)*

Motorcycle

ATV

Years of Experience Operating a Motorcycle*

Spouse - Years of Experience Operating a Motorcycle*

Number of Motorcycles*

Number of ATV's*

Number of Additional Operators/Drivers:*

Add'l Operator 1*

First Middle Last

Add'l Operator 1 - DOB*

Add'l Operator 1 - DL #*

Add'l Operator 1 DL State*

Add'l Operator 1 - Years of Motorcycle Experience

Add'l Operator 2*

First Middle Last

Add'l Operator 2 - DOB*

Add'l Operator 2 - DL #*

Add'l Operator 2 DL State*

Add'l Operator 2 - Years of Motorcycle Experience

Motorcycle 1

Is Motorcycle 1 Financed?*

Yes

Motorcycle 1 - Finance Company:*

Motorcycle 1 Year*

Motorcycle 1 Make*

Motorcycle 1 Model*

Motorcycle 1 - VIN

Motorcycle 1 - Engine Size (cc's)*

Motorcycle 1 Collision Deductible:*

Motorcycle 1 Comprehensive Deductible:*

Motorcycle 2

Is Motorcycle 2 Financed?*

Yes

Motorcycle 2 - Finance Company:*

Motorcycle 2 Year*

Motorcycle 2 Make*

Motorcycle 2 Model*

Motorcycle 2 - VIN

Motorcycle 2 - Engine Size (cc's)*

Motorcycle 2 Collision Deductible:*

Motorcycle 2 Comprehensive Deductible:*

Motorcycle 3

Is Motorcycle 3 Financed?*

Yes

Motorcycle 3 - Finance Company:*

Motorcycle 3 Year*

Motorcycle 3 Make*

Motorcycle 3 Model*

Motorcycle 3 - VIN

Motorcycle 2 - Engine Size (cc's)*

Motorcycle 3 Collision Deductible:*

Motorcycle 3 Comprehensive Deductible:*

ATV 1

ATV 1 - Primary Usage*

Recreational

Farm Use

Property Maintenance

Other

Is ATV 1 Registered for On-Road Use?*

Yes

Is ATV 1 Financed?*

Yes

ATV 1 - Finance Company:*

ATV 1 Year*

ATV 1 Make*

ATV 1 Model*

ATV 1 - VIN

ATV 1 - Engine Size (cc's)*

ATV 1 Collision Deductible:*

ATV 1 Comprehensive Deductible:*

ATV 2

ATV 2 - Primary Usage*

Recreational

Farm Use

Property Maintenance

Other

Is ATV 2 Registered for On-Road Use?*

Yes

Is ATV 2 Financed?*

Yes

ATV 2 - Finance Company:*

ATV 2 Year*

ATV 2 Make*

ATV 2 Model*

ATV 2 - VIN

ATV 2 - Engine Size (cc's)*

ATV 2 Collision Deductible:*

ATV 2 Comprehensive Deductible:*

ATV 3

ATV 3 - Primary Usage*

Recreational

Farm Use

Property Maintenance

Other

Is ATV 3 Registered for On-Road Use?*

Yes

Is ATV 3 Financed?*

Yes

ATV 3 - Finance Company:*

ATV 3 Year*

ATV 3 Make*

ATV 3 Model*

ATV 3 - VIN

ATV 3 - Engine Size (cc's)*

ATV 3 Collision Deductible:*

ATV 3 Comprehensive Deductible:*

Additional Details:

RV / CAMPER

Additional Details:*

BOAT / WATERCRAFT

Type of Watercraft*

Boat

Personal Watercraft

Number of Boats*

Number of Personal Watercrafts*

Number of Additional Boat Operators/Drivers:*

Add'l Operator 1*

First Middle Last

Add'l Operator 1 - DOB*

Add'l Operator 1 - DL #*

Add'l Operator 1 DL State*

Add'l Operator 2*

First Middle Last

Add'l Operator 2 - DOB*

Add'l Operator 2 - DL #*

Add'l Operator 2 DL State*

Add'l Operator 3*

First Middle Last

Add'l Operator 3 - DOB*

Add'l Operator 3 - DL #*

Add'l Operator 3 DL State*

Add'l Operator 4*

First Middle Last

Add'l Operator 4 - DOB*

Add'l Operator 4 - DL #*

Add'l Operator 4 DL State*

Add'l Operator 5*

First Middle Last

Add'l Operator 5 - DOB*

Add'l Operator 5 - DL #*

Add'l Operator 5 DL State*

Add'l Operator 6*

First Middle Last

Add'l Operator 6 - DOB*

Add'l Operator 6 - DL #*

Add'l Operator 6 DL State*

Boat 1

Boat 1 - Current Value

Is Boat 1 Financed?*

Yes

Boat 1 - Finance Company:*

Boat 1 - Storage Location when not in use:*

Residence (outside)

Residence (garage)

Marina / Boat Slip

Storage Facility

Other

Boat 1 Year*

Boat 1 Make*

Boat 1 Model*

Boat 1 - Hull ID Number

Boat 1 Length (in feet)*

Boat 1 - Type of Motor*

Boat 1 - Motor Manufacturer

Boat 1 - Motor Year

Boat 1 - Horsepower*

Boat 1 - Top Speed (in mph)*

Boat 1 Collision Deductible:*

Boat 1 Comprehensive Deductible:*

Boat 1 - Include Trailer Coverage*

Yes

Boat 1 - Trailer Info

Boat 1 - Trailer Year*

Boat 1 - Trailer Make*

Boat 1 - Trailer Model*

Boat 1 - Trailer Serial Number or VIN

Boat 1 - Trailer Length (in feet)*

Boat 1 - Value of Trailer

Boat 1 - Trailer Collision Deductible:*

Boat 1 - Trailer Comprehensive Deductible:*

Boat 2

Boat 2 - Current Value

Is Boat 2 Financed?*

Yes

Boat 2 - Finance Company:*

Boat 2 - Storage Location when not in use:*

Residence (outside)

Residence (garage)

Marina / Boat Slip

Storage Facility

Other

Boat 2 Year*

Boat 2 Make*

Boat 2 Model*

Boat 2 - Hull ID Number

Boat 2 Length (in feet)*

Boat 2 - Type of Motor*

Boat 2 - Motor Year*

Boat 2 - Motor Manufacturer

Boat 2 - Horsepower*

Boat 2 - Top Speed (in mph)*

Boat 2 Collision Deductible:*

Boat 2 Comprehensive Deductible:*

Boat 2 - Include Trailer Coverage*

Yes

Boat 2 - Trailer Info

Boat 2 - Trailer Year*

Boat 2 - Trailer Make*

Boat 2 - Trailer Model*

Boat 2 - Trailer Serial Number or VIN

Boat 2 - Trailer Length (in feet)*

Boat 2 - Value of Trailer

Boat 2 - Trailer Collision Deductible:*

Boat 2 - Trailer Comprehensive Deductible:*

Boat 3

Boat 3 - Current Value

Is Boat 3 Financed?*

Yes

Boat 3 - Finance Company:*

Boat 3 - Storage Location when not in use:*

Residence (outside)

Residence (garage)

Marina / Boat Slip

Storage Facility

Other

Boat 3 Year*

Boat 3 Make*

Boat 3 Model*

Boat 3 - Hull ID Number

Boat 3 Length (in feet)*

Boat 3 - Type of Motor*

Boat 3 - Motor Manufacturer

Boat 3 - Motor Year

Boat 3 - Horsepower*

Boat 3 - Top Speed (in mph)*

Boat 3 Collision Deductible:*

Boat 3 Comprehensive Deductible:*

Boat 3 - Include Trailer Coverage*

Yes

Boat 3 - Trailer Info

Boat 3 - Trailer Year*

Boat 3 - Trailer Make*

Boat 3 - Trailer Model*

Boat 3 - Trailer Serial Number or VIN

Boat 3 - Trailer Length (in feet)*

Boat 3 - Value of Trailer

Boat 3 - Trailer Collision Deductible:*

Boat 3 - Trailer Comprehensive Deductible:*

PWC 1

PWC 1 - Current Value

Is PWC 1 Financed?*

Yes

PWC 1 - Finance Company:*

PWC 1 - Storage Location when not in use:*

Residence (outside)

Residence (garage)

Marina / Boat Slip

Storage Facility

Other

PWC 1 Year*

PWC 1 Make*

PWC 1 Model*

PWC 1 - Hull ID Number

PWC 1 Length (in feet)*

PWC 1 - Top Speed (in mph)*

PWC 1 Collision Deductible:*

PWC 1 Comprehensive Deductible:*

PWC 1 - Include Trailer Coverage*

Yes

PWC 1 - Trailer Info

PWC 1 - Trailer Year*

PWC 1 - Trailer Make*

PWC 1 - Trailer Model*

PWC 1 - Trailer Serial Number or VIN

PWC 1 - Trailer Length (in feet)*

PWC 1 - Value of Trailer

PWC 1 - Trailer Collision Deductible:*

PWC 1 - Trailer Comprehensive Deductible:*

PWC 2

PWC 2 - Current Value

Is PWC 2 Financed?*

Yes

PWC 2 - Finance Company:*

PWC 2 - Storage Location when not in use:*

Residence (outside)

Residence (garage)

Marina / Boat Slip

Storage Facility

Other

PWC 2 Year*

PWC 2 Make*

PWC 2 Model*

PWC 2 - Hull ID Number

PWC 2 Length (in feet)*

PWC 2 - Top Speed (in mph)*

PWC 2 Collision Deductible:*

PWC 2 Comprehensive Deductible:*

PWC 2 - Include Trailer Coverage*

Yes

PWC 2 - Trailer Info

PWC 2 - Trailer Year*

PWC 2 - Trailer Make*

PWC 2 - Trailer Model*

PWC 2 - Trailer Serial Number or VIN

PWC 2 - Trailer Length (in feet)*

PWC 2 - Value of Trailer

PWC 2 - Trailer Collision Deductible:*

PWC 2 - Trailer Comprehensive Deductible:*

PWC 3

PWC 3 - Current Value

Is PWC 3 Financed?*

Yes

PWC 3 - Finance Company:*

PWC 3 - Storage Location when not in use:*

Residence (outside)

Residence (garage)

Marina / Boat Slip

Storage Facility

Other

PWC 3 Year*

PWC 3 Make*

PWC 3 Model*

PWC 3 - Hull ID Number

PWC 3 Length (in feet)*

PWC 3 - Top Speed (in mph)*

PWC 3 Collision Deductible:*

PWC 3 Comprehensive Deductible:*

PWC 3 - Include Trailer Coverage*

Yes

PWC 3 - Trailer Info

PWC 3 - Trailer Year*

PWC 3 - Trailer Make*

PWC 3 - Trailer Model*

PWC 3 - Trailer Serial Number or VIN

PWC 3 - Trailer Length (in feet)*

PWC 3 - Value of Trailer

PWC 3 - Trailer Collision Deductible:*

PWC 3 - Trailer Comprehensive Deductible:*

Additional Details:

PERSONAL UMBRELLA

Desired amount of liability coverage*

Please specify desired amount of liability coverage:*

Number of Household Vehicles*

Number of Owner-Occupied Homes*

Number of Rental Units owned*

Number of Household Boats/Watercrafts*

Number of Household Members under age 25*

Number of Household Off-Road Vehicles*

Number of Household Motorcycles*

Is there a business operated on the residence premises?*

Yes

Description of business:*

Is any farming conducted on the residence premises?*

Yes

Description of farming operations on residence premises:*

Does any member of the household hold an elected office or a high-profile position?*

Yes

Please describe the elected office or high-profile position:*

Additional Details:

LIFE INSURANCE

Type of Life Insurance:*

Term Life

Whole Life

Universal Life

Burial Policy

Other

Term Length*

Desired Coverage Amount:*

Gender*

Male

Female

Height*

Weight (lbs)*

Do you use any kind of nicotine or tobacco products?*

Yes

Have you ever had a life insurance application declined?*

Yes

Please provide details regarding your previous life insurance declination:*

Please select all medical conditions that apply:*

Cancer

Heart Disease / Heart Attack

Asthma

Sleep Apnea

Stroke

COPD / Emphysema

Crohn's Disease

Lupus

OTHER

Please provide details regarding your cancer:*

Please provide details regarding your heart disease / heart attack:*

Please provide details regarding your asthma:*

Please provide details regarding your sleep apnea:*

Please provide details regarding your stroke:*

Please provide details regarding your COPD / Emphysema:*

Please provide details regarding your Crohn's Disease:*

Please provide details regarding your Lupus:*

Please provide details regarding your unspecified medical condition(s):*

How many prescription medications do you take?*

Prescription 1 Details (dosage, frequency, year prescribed, and medical condition related to this medication):*

Prescription 2 Details (dosage, frequency, year prescribed, and medical condition related to this medication):*

Prescription 3 Details (dosage, frequency, year prescribed, and medical condition related to this medication):*

Prescription 4 Details (dosage, frequency, year prescribed, and medical condition related to this medication):*

Prescription 5 Details (dosage, frequency, year prescribed, and medical condition related to this medication):*

Prescription 6 Details (dosage, frequency, year prescribed, and medical condition related to this medication):*

Prescription 7 Details (dosage, frequency, year prescribed, and medical condition related to this medication):*

Prescription 8 Details (dosage, frequency, year prescribed, and medical condition related to this medication):*

Prescription 9 Details (dosage, frequency, year prescribed, and medical condition related to this medication):*

Prescription 10 Details (dosage, frequency, year prescribed, and medical condition related to this medication):*

Are your biological parents still living*

Yes

I don't know

Did either of your biological parents die prior to age 60 due to a heart-related condition?*

Yes

I don't know the cause of death

Please provide details related to the death of your parent(s) that was caused by a heart-related condition:*

Please provide any additional details that may be relevant to your life insurance application:

OTHER (Not Listed)

Additional Details:*

FINAL DETAILS

Would you like to be enrolled in Paperless documents?*

Yes

How would you like to receive your quote? (select all that apply)*

Phone Call

Text Message

Postal Mail

OTHER

Please specify delivery method:*

Additional Notes:

Form completed by:*

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