New Applicant Intake Form Step 1 of 9 11% Assign to in EZLynxAllison LynchAnnie PerezCarlos BustamanteCarrie CunninghamCassidy BennettDinora BenavidezEric RobertsKim RodriguezJames CardenasJennifer WallaceJohn HansonKlarissa SanchezLeslie CarlsonMorgan LeverettSharon LozaAssign to in Better AgencyAllison LynchAnnie PerezCarlos BustamanteCarrie CunninghamCassidy BennettDinora BenavidezKim RodriguezJennifer WallaceKlarissa SanchezLeslie CarlsonMorgan LeverettSharon LozaReferred By Name First Last How did you hear about My Insurance Group?Client ReferralFacebookGoogleLoan OfficerRealtorYouTubeWebsiteOtherHiddenDate MM slash DD slash YYYY Prospect Name(Required) First Last PhoneEmail(Required) Date of Birth MM slash DD slash YYYY SSN Occupation Marital Status Single Married Widowed Divorced Policies Being Quoted(Required) Auto Home (Existing) Home (New Purchase) Spouse Name First Last Date of Birth MM slash DD slash YYYY PhoneEmail Information For Home Being QuotedCurrent 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 What is the address of the property to be purchased?(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 What type of property is this? Primary Secondary Rental Year Home Was Built Purchase/Closing Date MM slash DD slash YYYY Sq Ft# of Stories 1 1.5 2 Bedrooms 1 2 3 4 5 Bathrooms11.522.533.544.5Garage No Garage 1 Car 2 Car 3 Car 4 Car Additional Structures Yes No Additional Structures More than 5 Acres? Yes No Fireplace Yes No Swimming Pool Yes No Type of Swimming Pool Inground Above Ground Swimming Pool Fenced?(Required) Yes No Diving Board/Slide?(Required) Yes No Gated Community? Yes No Monitored Alarm Yes No Dogs Yes No Dog Breeds Add RemoveSolar Panels Yes No Number of Solar PanelsExterior MaterialAluminum SidingAsbestosBrick VeneerHardy PlankStone VeneerStuccoVinyl SidingWoodYear Roof UpdatedYear Electrical UpdatedYear Plumbing Updated?Year HVAC UpdatedDwelling/Purchase PriceHow much coverage is required to rebuild your home?Loan/Mortgage AmountLiability $100,000 $300,000 $500,000 Any valuables you'd like to insure? Artwork Collectibles Firearms Jewelry Technology Other 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.Bundle Auto? Yes No Home Notes Driver InformationTotal Drivers In Home 1 2 3 4 5 Drivers License # Type of Driver Rated Excluded Driver #2Driver #2 First Last Date of Birth MM slash DD slash YYYY Drivers License # Driver Rated or Excluded? Rated Excluded Email PhoneOccupation Driver #3Driver #3 First Last Date of Birth MM slash DD slash YYYY Drivers License Driver Rated or Excluded? Rated Excluded Email PhoneOccupation Driver #4Driver #4 First Last Drivers License Driver Rated or Excluded? Rated Excluded Email PhoneOccupation Driver #5Driver #5 First Last Date of Birth MM slash DD slash YYYY Drivers License Driver Rated or Excluded? Rated Excluded Email PhoneOccupation Total Vehicles In Home 1 2 3 4 5 Vehicle #1Vehicle Year Make Model VIN Do you have a lien holder? Yes No Who is your lien holder? Vehicle #2Vehicle Year Vehicle Make Vehicle Model VIN Do you have a lien holder? Yes No Who is the lien holder? Vehicle #3Vehicle Year Vehicle Make Vehicle Model VIN Do you have a lien holder? Yes No Who is the lien holder? Vehicle #4Vehicle Year Vehicle Make Vehicle Model VIN Do you have a lien holder? Yes No Who is the lien holder? Are all the vehicles registered to the owner? Yes No Which vehicle are you not the registered owner to? Rideshare and/or Delivery Yes No Which vehicle are you designating for Rideshare and/or Delivery? Business Use Yes No Which vehicle is used for Business Use? Current Auto Liability Limits $30,000/$60,000/$30,000 $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 $300,000 Combined Single Limit $500,000 Combined Single Limit This covers costs associated with injuries and death that you or another driver causes while driving your car. This coverage will reimburse others for damage that you or another driver operating your car causes to another vehicle or other property, such as a fence, building or utility pole.UM/UIM Limits $30,000/$60,000/$25,000 $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 $300,000 Combined Single Limit $500,000 Combined Single Limit Reimburses you when an accident is caused by an uninsured motorist—or in the case of a hit-and-run. You can also purchase under insured motorist coverage, which will cover costs when another driver lacks adequate coverage to pay the costs of a serious accident.Collision Deductible $100 $250 $500 $750 $1,000 No Collision Coverage This optional coverage reimburses you for damage to your car that occurs as a result of a collision with another vehicle or other object—e.g., a tree or guardrail—when you’re at fault. While collision coverage will not reimburse you for mechanical failure or normal wear-and-tear on your car, it will cover damage from potholes or from rolling your car.Comprehensive Deductible $100 $250 $500 $750 $1,000 No Comp Coverage This provides coverage against theft and damage caused by an incident other than a collision, such as fire, flood, vandalism, hail, falling rocks or trees and other hazards—even getting hit by an asteroid!Are any of your Vehicles Liability only? Yes No Which vehicle is Liability only? PIP or Medical Payments PIP Medical Payments Decline Both Provides reimbursement for medical expenses for injuries to you or your passengers. PIP will also cover lost wages and other related expenses.Coverage Amount $2,500 $5,000 $10,000 Roadside Assistance Yes No Rental Reimbursement Yes No This coverage pays for a rental car if your vehicle is damaged and undriveable due to a covered loss. This coverage does NOT pay for a rental car when your vehicle is being repaired for any other reason. Please upload your current policy documents (if available) Drop files here or Select files Max. file size: 5 MB. Do you have any fears, concerns or expectation regarding your insurance?Do you have any hypothetical claim scenarios or situations in the past that would like to discuss?CAPTCHA
