Personal Lines Insurance Discovery Form in San Antonio, TX

PL - Discovery Form - Agent Facing

Use the following form to request a home insurance quote if it will be your primary residence.

"*" indicates required fields

Step 1 of 16 - Personal Info

Let's start with the basics

Primary Producer*

CSR

Person completing this form:*

This field is hidden when viewing the form

Today's Date*

MM slash DD slash YYYY

Name*

First Last

What is your date of birth?*

MM slash DD slash YYYY

Check if applicable:

Spanish speaker only

What is your email address?*

What is your cell phone number?*

Can we text you?*

Yes, you can text me about my policy.

No, do not text me about my policy.

What is your communication preference?*

Phone

Text

In office consultation

What is your occupation?*

Are you married?*

Married

Single

Domestic Partner

What Is Your Spouse's/Partner's Name?*

First Last

Spouse's/Partner's Occupation*

Spouse's/Partner's Date of Birth*

MM slash DD slash YYYY

Do you know your spouse's / partner's email?*

Yes

Spouse's/Partner's Email

Spouse's/Partner's Cell Phone*

How did you hear about My Insurance Group?*

Please be specific. If you were referred by a person, please put the person's name.

What insurance quotes are you requesting? Check all that apply.*

Homeowners / Townhome

Condo

Personal Auto

Landlord / Rental / Investment Property

Flood. Rising water coming into my house.

Renters. I'm renting a home/apartment.

Wind Policy. I live on the coast.

Personal Umbrella

Watercraft

RV / Motorhome / Travel Trailer

Motorcycle / ATV / UTV

Scheduled Personal Property ONLY

Life Insurance

Other not listed

The more policies, the bigger the bundle discount.

Quote request not listed:

Homeowners / Townhome Quote

Help us understand why you are shopping for insurance and address a few common questions.

What has you shopping for home / townhome insurance?*

I'm purchasing a house / townhome.

My current premiums are too expensive.

I'm seeking better service and/or communication.

I had a bad claims experience with my current carrier.

Other

Please explain:*

Congratulations! What is your estimated closing date?*

MM slash DD slash YYYY

Is this your first home purchase?*

Yes

Who is your current insurance carrier(s)?*

What are you currently paying for the policy?*

Enter either your monthly or annual premium.

Address Details

What is the address you INTEND to purchase?*

This is the address you are looking to insure.

Street Address City State ZIP Code

What is your CURRENT address?*

Where do you live now?

Street Address City State ZIP Code

Purpose of residence

What is the intended use of this residence?*

Primary Residence

Primary Residence with intent to Rent other side (Duplex)

Secondary Residence with NO intent to Rent

Secondary Residence with intent to Rent

Other

Leasing Period*

Long Term (weeks at a time)

Short Term to include daily rentals

Is the home title to a business entity, estate or trust?*

Yes

Name of business entity, estate, or trust*

Basic Underwriting Details

It is important that you provide us with the best, most update information you can so that we may apply available discounts and best rating that your home will qualify for.

What year was the roof last replaced?*

Do you have or will there be any dogs, farm, or exotic animals?*

Yes

Please list the dog breeds, farm or exotic animals you keep on property*

Is there a pool?*

Yes

Is there a slide?*

Yes

Is there a diving board?*

Yes

Is there Scheduled Personal Property to be considered

In the event of a claim, the common policy in Texas caps jewelry at $1500 per piece. Other items may cap at $2500. The purpose of this field is to bring awareness to the exposure.

Scheduled Personal Property Details

What type of item are we scheduling?	Description of Item	Value	Appraisal Date	Actions

There are no Entries.

Maximum number of entries reached.

Supporting Documentation

Upload current home declaration page if available:

Max. file size: 5 MB.

Condo

What has you shopping for condo insurance?*

I'm purchasing a condo.

My current premiums are too expensive.

I'm seeking better service and/or communication.

I had a bad claims experience with my current carrier.

Other

Congratulations! What is your estimated closing date?*

MM slash DD slash YYYY

Is this your first home purchase?*

Yes

Who is your current insurance carrier?*

How much are you currently paying?*

Address Details

What is the address you intend to purchase?

Street Address City State ZIP Code

What is your current address?

Street Address City State ZIP Code

Purpose of Residence

What is the intended use of the condo?*

Primary Residence

Secondary Residence with NO intent to rent

Secondary Residence with intent to rent

Other

Leasing period*

Long Term (weeks at a time)

Short Term to include daily rentals

Is the home title to a business entity, estate or trust?

Yes

Name of entity, estate, or trust*

How much money would it take to replace all your personal belongings in the event of a fire causing a total loss?*

This value needs to include all your furniture, clothes, common electronics, etc.

Basic Underwriting Details

It is important that you provide us with the best, most update information you can so that we may apply available discounts and best rating that your home will qualify for.

What story of the building is your unit on?*

Do you have or will there be dogs, farm, or exotic animals?*

Yes

Please list the dog breeds, farm or exotic animals you keep on property*

Is there Scheduled Personal Property to be considered

What type of item are we scheduling?	Description of Item	Value	Actions

There are no Entries.

Maximum number of entries reached.

Supporting Documentation

Max. file size: 5 MB.

Auto Quotes

Do you currently have auto insurance?*

Yes

Are you aware of your current liability limits?*

Yes

Why not?*

What has you shopping for auto insurance?*

I'm looking to bundle and save money.

I'm seeking better service and/or communication.

I had a bad claims experience with my current carrier.

My current premiums are too expensive.

Other

Please explain:*

Who is your current insurance carrier(s)?*

What are you currently paying for the policy? Enter either your monthly or annual premium.*

What is your address?*

Where do you live now?

Street Address City State ZIP Code

Driver Details

Please list ALL household members 15 and older to include non-licensed.

Name	Date of Birth	Driver's License Number	Any tickets or accidents in the last 5 years?	Actions

There are no Entries.

Maximum number of entries reached.

Vehicle Details

Vehicles to be insured:

Year	Make	Model	Vehicles primary use:	Comprehensive Deductible?	Collision Deductible?	Any custom parts or equipment over $1000	Is there a lienholder?	Actions

There are no Entries.

Maximum number of entries reached.

Supporting Documentation

Upload current auto declaration page if available:

Max. file size: 5 MB.

Landlord / Rental / Investment

Help us understand why you are shopping for insurance and address a few common questions.

What has you shopping for landlord insurance?*

I'm purchasing an investment property to be rented to others.

My current premiums are too expensive.

I'm seeking better service and/or communication.

I had a bad claims experience with my current carrier.

Other

Please explain:

Congratulations! What's your estimated closing date?*

MM slash DD slash YYYY

Is this your first landlord property?*

Yes

What is your mailing address?*

Street Address City State ZIP / Postal Code

This is the address all policy related documents will be mailed.

Property Details

Property to be quoted:

Address of property to be insured:	Age of Roof	Monthly Rental Income:	Is the property professionally managed?	Actions

There are no Entries.

Maximum number of entries reached.

Are there more properties in your investment portfolio?*

Yes

How many?*

Supporting Documentation

Please upload current declaration pages or a document listing all the properties if available:

Max. file size: 5 MB.

Flood Quote

This section is for rising ground water outside coming into your home. Generally flood is required by mortgage company if dwelling is in a flood zone, however, people outside high - risk flood zones file more than 20% of all NFIP claims.

What is the mailing address?*

Street City State Zip

Property to be quoted:

What is the address of the property to be insured:	Are you aware there may be a 30 day waiting period once policy is paid in full?	The current National Flood Insurance Program (NFIP) limits cap at $250K building coverage and $100K contents. Will you need higher limits to repair/rebuild/replace the dwelling and contents in the event of a flood.	Actions

There are no Entries.

Maximum number of entries reached.

Supporting Documentation

Please upload elevation certificate or current policy if available.

Max. file size: 5 MB.

Renters Quote

What is the address of the property you are renting?

Street Address City State ZIP Code

How much money would it take to replace all your personal belongings in the event of a fire causing a total loss?*

This value needs to include all your furniture, clothes, common electronics, etc.

Scheduled Personal Property to be considered

What type of item are we scheduling?	Value	Appraisal Date	Actions

There are no Entries.

Maximum number of entries reached.

Is the property manager requiring to be an additional insured/interest?*

Yes

What is the property management clause provided?*

Supporting Documentation

Please upload any supporting documents:

Max. file size: 5 MB.

Wind Quote

Most carriers do not offer wind coverage for properties on the coast. A wind policy is a monoline policy generally provided by Texas Windstorm to supplement the wind exposure.

Do you have a current wind policy?*

Yes

Who is the current wind carrier?*

What is the mailing address for policy?*

Street Address City State ZIP Code

This is the address all policy related documents will be mailed.

Property needing a wind quote:

What is the address of the property needing a wind quote:	Is the property in a hazardous flood zone?	Are you aware of or have a WPI8 wind certificate of compliance?	What is the purpose of the policy?	Actions

There are no Entries.

Maximum number of entries reached.

Supporting Documentation

Please upload any supporting documents such as WPI8 or current policy:

Max. file size: 5 MB.

Personal Umbrella Quote

A personal umbrella provides additional liability protection in a situation resulting in injury to someone else or damage to their property where the damage exceeds the limits on your homeowners or auto insurance.

Do you currently have an umbrella policy elsewhere?*

Yes

Who is your current umbrella carrier?*

What is the limit of your current umbrella?*

What kind of personal umbrella are you requesting?*

Traditional Umbrella extending to auto and other properties

Premises Only

Desired Coverage Limit*

$1 million

$2 million

$3 million

$4 million

$5 million

** Desired limit may be subject to underwriting approval. **

Property Questions

How many single family dwellings and duplexes do you own?*

How many triplex and quadplexes do you own?*

How many of your properties have swimming pools?*

Vehicles Questions

How many autos do you have?*

How many motorcycles/mopeds do you have?*

How many motorhomes / RVs do you have?*

How many boats do you have?*

Number of boats exceeding 150 horsepower with max speed of 75 mph?*

Number of boats with 150 - 300 horsepower with max speed of 75 mph?*

Number of boats with 301 plus horsepower with max speed of 75*

Driver Questions

How many drivers are 22 and Over?*

How many drivers are under 22 with a clean driving record?*

How many drivers have been licensed than 1 year?*

How many drivers are under 22 without a clean driving record?*

How many drivers will be excluded from umbrella?*

Are any household members not listed or excluded on the underlying auto policy?*

Are any individuals outside of the household listed on the underlying auto policy?*

How many at fault accidents in the last 3 years for all covered drivers?*

How many moving violations in the last 3 years for all covered drivers?*

How many MAJOR violations in the last 3 years for all covered drivers?*

Example: driving under the influence of alcohol or drugs, reckless driving, careless driving, or negligent driving.

Supporting Documentation

Please upload any supporting documents such current declaration pages:

Max. file size: 5 MB.

Watercraft

What has you shopping for watercraft insurance?*

I'm purchasing a watercraft.

My current premiums are too expensive.

I'm seeking better service and/or communication.

I had a bad claims experience with my current carrier.

Other

Have you had watercraft insurance in the last 12 months?*

Yes

Are you aware of your current liability limits?*

Yes

Who is your current watercraft insurance carrier?*

How much are you currenty paying?*

What is your mailing address?

Street Address City State ZIP Code

Primary Residence:*

Own Home / Condo

Own Manufactured Home

Rent

Live with parents

Other

Watercraft(s) to be quoted:

Watercraft Details:

Year:	Make	Model:	Hull Length	Maximum Speed:	Market Value of the watercraft:	Where is the watercraft kept during the boating season?	Actions

There are no Entries.

Maximum number of entries reached.

Drivers or Operators who have an interest in the watercraft

Anyone who uses or has regular access to the insured vehicle more than 12 times per year (NOTE: operators under 18 who are household members or have permissive use are acceptable and do not have to be listed in order to be covered; operators 18 or older will be rated)

Driver Details:

Name	Date of Birth	Driver's License Number	Have you completed a watercraft safety course in the last 3 years?	Actions

There are no Entries.

Maximum number of entries reached.

Supporting Documentation

File

Max. file size: 5 MB.

RV / Motorhome / Travel Trailer

What has you shopping for RV / Travel Trailer insurance?*

I'm purchasing a RV / Travel Trailer.

My current premiums are too expensive.

I'm seeking better service and/or communication.

I had a bad claims experience with my current carrier.

Other

Have you had RV / Travel Trailer insurance in the last 12 months*

Yes

Are you aware of your current liability limits?*

Yes

Who is your current carrier?*

How much are you currently paying?*

What is your mailing address?*

Street Address City State ZIP Code

Primary Residence:*

Own Home / Condo

Own Manufactured Home

Rent

Live with parents

Other

Drivers

Anyone who has regular access to drive.

Drivers to be listed:

Name	Date of Birth	Driver Status	Driver's License Number	Years RV / Travel Trailer Operating Experience:	Any tickets or accidents in the last 5 years?	Please explain:	Actions

There are no Entries.

Maximum number of entries reached.

RV / Travel Trailer Details:

RV /Travel Trailers to be quoted:

Is this for an RV or a travel trailer?	Year:	Make:	Model:	Comprehensive Deductible:	Collision Deductible:	Actions

There are no Entries.

Maximum number of entries reached.

Supporting documentation:

Max. file size: 5 MB.

Motorcycle / ATV / UTV

What has you shopping for motorcylce / ATV / UTV insurance?*

I'm purchasing a motorcycle / ATV / UTV.

My current premiums are too expensive.

I'm seeking better service and/or communication.

I had a bad claims experience with my current carrier.

Other

Have you had this vehicle insured in the last 12 months*

Yes

Are you aware of your current liability limits?*

Yes

Who is your current carrier?*

How much do you currently pay?*

What is your current address?

Street Address City State ZIP Code

Primary Residence:*

Own Home / Condo

Own Manufactured Home

Rent

Live with parents

Other

Drivers

Drivers to be listed:

Name	Date of Birth	Driver's License Number	Any tickets or accidents in the last 5 years?	Actions

There are no Entries.

Maximum number of entries reached.

Vehicle Details:

Vehicles to be lister:

Year:	Make	CC size:	Comprehensive Deductible:	Collision Deductible:	Actions

There are no Entries.

Maximum number of entries reached.

Supporting Documentation

Max. file size: 5 MB.

Scheduled Personal Property

Property to Scheduled:

What type of item are we scheduling?	Description of Item	Value	Actions

There are no Entries.

Maximum number of entries reached.

Supporting Documentation:

Max. file size: 5 MB.

Agency Discovery Questions

What is your time frame to move forward?

MM slash DD slash YYYY

How did you end up with your current insurance carrier/agent?*

Have you worked with an insurance broker before? Do you know what we do? How we get paid?*

Yes

Do you have any concerns or claims scenarios / experiences you'd like to share?*

Deductibles? Bad experiences? Scenarios you haven't experienced but caught your attention?

As your agency moving forward, what do you expect from us?*

Who all is going to be involved in making the decision to move forward?*

Notes to Agent:*

What other policies do you have:

Select all opportunities in portfolio:

Needs: Auto

Needs: Motorcycle

Needs: Watercraft

Needs: ATV / Golf Cart / UTV

Needs: PAF

Needs: Umbrella

Needs: Flood

Needs: Wind

Needs: Commercial

Needs: Landlord

Needs: Home

Needs: RV / Travel Trailer

Schedule your Follow-up Appointment below:

Schedule Follow-up Call

Authorization*

I agree to the following:

By submitting this request you are authorizing My Insurance Group, LLC, its affiliates and carrier partners the access to pull the necessary reports (i.e. claims, credit and loss history) to confirm the data submitted. Submitting your quote request does not constitute a binding confirmation of a new or revised insurance coverage.

My Insurance Group, LLC is committed to respecting your privacy and communication preferences. So that we may remain compliant with state and federal regulations, we need your expressed permission to communicate with you through phone, Ai outreach, text and email as needed.

You may opt-out of all future communication at any time by making your preferences known to us.

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Carriers to quote:

Homowners:

Allied Trust

Allstate

American Modern

Chubb

Germania

Hartford

Mercury

Nat Gen

Nationwide

Progressice / ASI

Safeco

Safepoint

Sagesure

South and Western

Travelers

Other to be specified in email

Condo:

First Choice

Second Choice

Third Choice

Personal Auto:

Allstate

American Modern

Bristol West

Chubb

Germania

Hagerty

Hartford

Mercury

Nat Gen

Nationwide

Progressive

Safeco

Travelers

Landlord / Rental / Investment:

Allied Trust

Allstate

American Modern

Germania

OSC

Sagesure

South and Western

Tower Hill

Wellington

Renters:

First Choice

Second Choice

Third Choice

Flood:

The Hartford

Wrighflood

Neptune

Wind:

Texas Windstorm

Include in property quote

Personal Umbrella:

RLI

Follow Auto Carrier

Third Choice

Watercraft:

American Modern

Progressive

Safeco

Travelers

RV / Motorhome / Travel Trailer:

First Choice

Second Choice

Third Choice

Motorcycle / ATV / UTV:

First Choice

Second Choice

Third Choice

Scheduled Personal Property:

First Choice

Second Choice

Third Choice

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Team Member*

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