New Personal Lines Intake

Belmont – PL Intake

Step 1 of 13

Primary Insured Information

Primary Insured Name

First Last

Phone

Drivers License

Date of Birth

MM slash DD slash YYYY

Occupation

Employer

Marital Status

Spouse Information

Spouse Name

First Last

Spouse Phone

Spouse Email

Spouse Birth Date

MM slash DD slash YYYY

Spouse Occupation

How did you hear about us?

Client Referral

Mortgage Referral

Realtor Referral

Financial Advisor Referral

Other Referral

Facebook

Google

Instagram

Other

Referred By Name

First Last

What type of insurance can we quote for you?

Auto

Home

Condo

Umbrella

Investment Property

Motorcycle/Slingshot/ATV

Golf Cart

Boat

Other

What other type of insurance can we quote for you?

New purchase or already own the condo/home?

New Purchase

Already Own

Expected Closing Date

MM slash DD slash YYYY

How do you use the condo?

Primary Residence

Secondary Residence

Rental

Current Address (No PO Boxes)

Street Address Address Line 2 City State ZIP Code

Address of Property Being Purchased

Same as current address

Street Address Address Line 2 City State ZIP Code

Would you like to add a different mailing address?

Yes

Mailing Address

Street Address Address Line 2 City State ZIP Code

Home/Condo Information

Year Built

Purchase Date

MM slash DD slash YYYY

Sq Ft

Bedrooms

# of stories

1.5

Bathrooms

Garage

None

1 Car

2 Car

3 Car

4 Car

Additional Structures

Yes

Additional Structure Description

Number of Acres

Fireplace

Yes

Diving Board or Slide?

Yes

Swimming Pool

Yes

Swimming Pool Enclosed/Fenced?

Yes

Monitored Burglar/Fire Alarm?

Yes

Dog(s)?

Yes

Dog Breeds

If mixed please indicate type of mix.

Any bite history or security training?

Yes

Have you had any home or renter's insurance claims in the past 5 years?

Yes

Home Information Continued

Exterior Material

Roof Material

Roof Shape

Year Roof Updated

Year Electrical Updated

Year Plumbing Updated?

Year HVAC Updated

Current Insurer

Expiration Date

MM slash DD slash YYYY

Dwelling

Current Dwelling Limits

Wind/Hail Deductible

All Other Perils Deductible

Loss of Use

Other Structures

Personal Property

Liability

$300,000

$500,000

$1,000,000

Medical Payments

$5,000

$10,000

$25,000

$50,000

Closing Date

MM slash DD slash YYYY

Scheduled Personal Property

Artwork

Collectibles

Firearms

Jewelry

Technology

Other

Valuable Items List (Click the + to add additional items)

Item Description

Replacement Value

Purchase Date

Please list each item and include an appraised/estimated value. Only one item per row please.

Has home been non-renewed in past 3 years?

Home Notes

Auto Information

Total Drivers in Home

Total Vehicles in Home

Driver #2

Name(Required)

First Last

Date of Birth

MM slash DD slash YYYY

Drivers License

Phone

Occupation

Relationship(Required)

Spouse

Child

Parent

Domestic Partnership

Other

Driver #3

Name(Required)

First Last

Date of Birth

MM slash DD slash YYYY

Drivers License

Phone

Occupation

Relationship to you(Required)

Spouse

Child

Parent

Domestic Partnership

Other

Driver #4

Name(Required)

First Last

Date of Birth

MM slash DD slash YYYY

Drivers License

Phone

Occupation

Relationship to you(Required)

Spouse

Child

Parent

Domestic Partnership

Other

Driver #5

Name(Required)

First Last

Date of Birth

MM slash DD slash YYYY

Drivers License

Phone

Occupation

Relationship to you(Required)

Spouse

Child

Parent

Domestic Partnership

Other

Auto Coverage Info

Liability Limits

$100,000/$300,000/$100,000

$250,000/$500,000/$250,000

$300,000 CSL

$500,000 CSL

UM/UIM

$100,000/$300,000/$100,000

$250,000/$500,000/$250,000

$300,000 CSL

$500,000 CSL

Physical Damage?

Comprehensive

Collision

Comprehensive Deductible

Collision Deductible

Rental Reimbursement

Yes

Rental Reimbursement

$30/Day

$50/Day

Vehicle #1

Vehicle Year

Make

Model

VIN

Business Use

Pleasure

Commute

Business

Other

Rideshare or Delivery?

Yes

Vehicle #2

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Pleasure

Commute

Business

Other

Rideshare or Delivery

Yes

Rental Reimbursement

Yes

Rental Reimbursement

$30/Day

$50/Day

Physical Damage?

Comprehensive

Collision

Vehicle #3

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Pleasure

Commute

Business

Other

Rideshare or Delivery

Yes

Rental Reimbursement

Yes

Rental Reimbursement

$30/Day

$50/Day

Physical Damage?

Comprehensive

Collision

Vehicle #4

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Pleasure

Commute

Business

Other

Rideshare or Delivery

Yes

Rental Reimbursement

Yes

Rental Reimbursement

$30/Day

$50/Day

Physical Damage?

Comprehensive

Collision

Vehicle #5

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Pleasure

Commute

Business

Other

Rideshare or Delivery

Yes

Rental Reimbursement

Yes

Rental Reimbursement

$30/Day

$50/Day

Physical Damage?

Comprehensive

Collision

Investment Property

Address

Street Address Address Line 2 City State ZIP Code

Property Status

Currently Occupied with Tenants

Listed For Sale – No Occupants

Listed For Rent – No Occupants

Undergoing Renovations – Vacant

Additional notes:

Motorcycle/Slingshot/ATV

Name of Primary Driver

First Last

Vehicle Type

Motorcycle

Slingshot

ATV

Is Vehicle Used for Racing?

Yes

Current Motorcycle License

Yes

Has Driver Completed Safety Course?

Yes

Year

Make

Model

VIN

Umbrella

How many homes do you own?

This includes primary, secondary, vacation, rental and investment properties.

How many vehicles do you own?

Do you own any of the following items?

Boat/Yacht

Motorcycle

ATV

Golf Cart

Vacant Land

Any LLC or Trust need listed on umbrella?

What umbrella limit?

Boat Information

Where is boat stored?

Primary Residence

Marina – Slip

Marina – Dry Stack

Other

Year

Make

Model

Hull Number

Motor Type

Inboard

Outboard

Top Speed (MPH)

Boat Length

Boat is used for racing?

Yes

Do you own a boat trailer?

Yes

Golf Cart

Year

Make

Model

Primary Use

Transportation

Golfing

Fuel Type

Electric

Gas

Recreational Vehicle

RV Type

5th Wheel

Motorcoach

Other

Year

Make

Model

Please add any additional information here

Please upload current policy documents if you have them available.

Max. file size: 5 MB.

Consent(Required)

Belmont Insurance Group may contact me via phone call, email and text message.

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Belmont – PL Intake

Primary Insured Information

Spouse Information

Home/Condo Information

Home Information Continued

Auto Information

Driver #2

Driver #3

Driver #4

Driver #5

Auto Coverage Info

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

Vehicle #5

Investment Property

Motorcycle/Slingshot/ATV

Umbrella

Boat Information

Golf Cart

Recreational Vehicle

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