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EWS Ins – PL Intake V1
EWS Ins – PL Intake V1
EWS Ins - PL Intake V1
Step
1
of
13
7%
Primary Insured Information
Primary Insured Name
(Required)
First
Last
Phone
Email
(Required)
Drivers License
Date of Birth
MM slash DD slash YYYY
Occupation
Employer
Marital Status
(Required)
Single
Married
Divorced
Widowed
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?
(Required)
Auto
Home
Condo
Umbrella
Investment Property
Motorcycle/Slingshot/ATV
Golf Cart
Boat
RV
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)
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Address of Property Being Purchased
Same as current address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Would you like to add a different mailing address?
Yes
No
Mailing Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home/Condo Information
Year Built
Purchase Date
MM slash DD slash YYYY
Sq Ft
Bedrooms
1
2
3
4
5
# of stories
1
1.5
2
Bathrooms
1
1.5
2
2.5
3
3.5
4
4.5
Garage
None
1 Car
2 Car
3 Car
4 Car
Additional Structures
Yes
No
Additional Structure Description
Number of Acres
Fireplace
(Required)
Yes
No
Diving Board or Slide?
Yes
No
Swimming Pool
(Required)
Yes
No
Swimming Pool Enclosed/Fenced?
Yes
No
Monitored Burglar/Fire Alarm?
Yes
No
Dog(s)?
(Required)
Yes
No
Dog Breeds
Add
Remove
If mixed please indicate type of mix.
Any bite history or security training?
Yes
No
Are you aware of any previous settlement or sinkhole issues on the property?
Yes
No
Have you had any home or renter's insurance claims in the past 5 years?
Yes
No
Home Information Continued
Exterior Material
Brick Veneer
Clapboard
Vinyl Siding
Stone Veneer
Stucco
Roof Material
Composite Shingles
Asphalt Shingles
Architectural Shingles
Metal
Tile
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
Odometer Reading
Purchase Date
MM slash DD slash YYYY
Wind/Hail Deductible
All Other Perils Deductible
Loss of Use
Other Structures
Personal Property
Liability
$10,000
$15,000
$30,000
$100,000
$300,000
$500,000
Medical Payments
$5,000
$25,000
$50,000
Loan Amount
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
Add
Remove
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?
Yes
No
Home Notes
Auto Information
Total Drivers in Home
1
2
3
4
5
Total Vehicles in Home
1
2
3
4
5
Driver #2
Name
(Required)
First
Last
Date of Birth
MM slash DD slash YYYY
Drivers License
Phone
Email
Occupation
Relationship
(Required)
Spouse
Child
Parent
Domestic Partnership
Other
Driver #3
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Drivers License
(Required)
Phone
Email
Occupation
Relationship to you
(Required)
Spouse
Child
Parent
Domestic Partnership
Other
Driver #4
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Drivers License
(Required)
Phone
Email
Occupation
Relationship to you
(Required)
Spouse
Child
Parent
Domestic Partnership
Other
Driver #5
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Drivers License
(Required)
Phone
Email
Occupation
Relationship to you
(Required)
Spouse
Child
Parent
Domestic Partnership
Other
Auto Coverage Info
Liability Limits
$50,000/$100,000/$50,000
$100,000/$300,000/$100,000
$250,000/$500,000/$250,000
$300,000 CSL
$500,000 CSL
UM/UIM
$50,000/$100,000/$50,000
$100,000/$300,000/$100,000
$250,000/$500,000/$250,000
$300,000 CSL
$500,000 CSL
Comprehensive Deductible
Decline Comp
$100
$250
$500
$1,000
Collision Deductible
Decline Collision
$100
$250
$500
$1,000
Rental Reimbursement
Yes
No
Rental Reimbursement
$30/Day
$50/Day
Vehicle #1
Vehicle Year
(Required)
Make
(Required)
Model
(Required)
VIN
(Required)
Business Use
Yes
No
Rideshare or Delivery?
Yes
No
Vehicle #2
Vehicle Year
(Required)
Vehicle Make
(Required)
Vehicle Model
(Required)
VIN
(Required)
Business Use
Yes
No
Rideshare or Delivery
Yes
No
Rental Reimbursement
Yes
No
Rental Reimbursement
$30/Day
$50/Day
Comprehensive Deductible
Decline Comp
$100
$250
$500
$1,000
Collision Deductible
Decline Collision
$100
$250
$500
$1,000
Vehicle #3
Vehicle Year
(Required)
Vehicle Make
(Required)
Vehicle Model
(Required)
VIN
(Required)
Business Use
Yes
No
Rideshare or Delivery
Yes
No
Rental Reimbursement
Yes
No
Rental Reimbursement
$30/Day
$50/Day
Comprehensive Deductible
Decline Comp
$100
$250
$500
$1,000
Collision Deductible
Decline Collision
$100
$250
$500
$1,000
Vehicle #4
Vehicle Year
(Required)
Vehicle Make
(Required)
Vehicle Model
(Required)
VIN
(Required)
Business Use
Yes
No
Rideshare or Delivery
Yes
No
Rental Reimbursement
Yes
No
Rental Reimbursement
$30/Day
$50/Day
Comprehensive Deductible
No Comp
$100
$250
$500
$1,000
Collision Deductible
No Collision
$100
$250
$500
$1,000
Vehicle #5
Vehicle Year
(Required)
Vehicle Make
(Required)
Vehicle Model
(Required)
VIN
(Required)
Business Use
Yes
No
Rideshare or Delivery
Yes
No
Rental Reimbursement
Yes
No
Rental Reimbursement
$30/Day
$50/Day
Comprehensive Deductible
No Comp
$100
$250
$500
$1,000
Collison Deductible
No Collision
$100
$250
$500
$1,000
Investment Property
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Property Status
Currently Occupied with Tenants
Listed For Sale - No Occupants
Listed For Rent - No Occupants
Undergoing Renovations - Vacant
Motorcycle/Slingshot/ATV
Name of Primary Driver
First
Last
Vehicle Type
Motorcycle
Slingshot
ATV
Is Vehicle Used for Racing?
Yes
No
Current Motorcycle License
Yes
No
Has Driver Completed Safety Course?
Yes
No
Year
Make
Model
VIN
Umbrella
In order to purchase an umbrella liability policy you must have auto liability limits of at least $250,000/$500,000/$250,000 and home/renters liability of at least $300,000.
I understand that if the current liability limits on my auto and home/renters policies do not meet those minimums I will not be eligible to purchase an umbrella liability policy.
How many homes do you own?
This includes primary, secondary, vacation, rental and investment properties.
How many home/renters claims have you made in the last 5 years?
How many vehicles do you own?
How many auto claims have you made in the last 5 years?
Any drivers on your auto policy have an at-fault accident in the last 5 years?
Yes
No
Do you own any of the following items?
Boat/Yacht
Motorcycle
ATV
Golf Cart
Vacant Land
Business
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
No
Do you own a boat trailer?
Yes
No
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: 10 MB.
Consent
SICA Insurance and Financial Services may contact me via phone call, email, and text message.
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