Intake Form

1. Client Information

Full Name

First Last

Date of Birth

Address

Street Address City State ZIP Code

Best phone number

Email

Preferred communication method

Phone

Text

Email

How did you hear about us?

2. Current Insurance Details

Who is your current insurance carrier?

What is your current renewal date?

What do you like/dislike about your current coverage or company?

What’s motivating you to shop for insurance right now? (ex: rate increase, coverage concerns, life change, etc.)

3. Household & Vehicles (Auto Quotes)

Total number of drivers:

Driver info (name, DOB, license #, marital status):

Any tickets/accidents/claims in the last 3-5 years?

Total number of vehicles:

Vehicle info (year, make, model, VIN if available):

Any custom parts, accessories, or modifications?

How are the vehicles primarily used? (Commute, business, pleasure, etc.)

Annual mileage per vehicle:

Do you have an existing loan/lease on any vehicles?

4. Home / Property Information

(Skip if auto only)

Address (if different from mailing):

Street Address City State ZIP Code

Type:

Year built:

Square footage:

Roof type and year replaced:

Any recent updates (roof, plumbing, electrical, HVAC)?

Finished Basement:

Any detached structures or sheds to cover?

Dogs or exotic pets? (breed if applicable)

Pool / trampoline / wood stove?

Do you currently have a home security system?

5. Additional Coverage Needs

Do you own any recreational vehicles (ATV, boat, RV, motorcycle, trailer)?

Do you own a business or rental property?

Do you have a trust or LLC associated with your property?

Are you interested in an umbrella policy for extra protection?

Any valuables (jewelry, collectibles, firearms, etc.) you’d like covered?

6. Discount Opportunities

Do you bundle home and auto now?

Occupation:

Highest level of education:

Military service:

Paperless billing & autopay ok?

Would you like us to review your life or health insurance options too?

7. Wrap-Up

Do you have any specific concerns or coverage questions?

What’s most important to you in an insurance company? (price, service, coverage, simplicity, etc.)

When would you like to have your quote reviewed with you?