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Personal Quote
SICA Ins - PL Intake
Step
1
of
12
8%
Primary Insured Information
Primary Insured Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Date of Birth
MM slash DD slash YYYY
DL State
DL #
Occupation
Industry
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 Company Referral
Realtor Referral
Loan Officer Referral
Other Referral
Facebook
Google
Instagram
Other
What type of insurance can we quote for you?
(Required)
Auto
Home
Condo
Umbrella
Investment Property
Motorcycle/Slingshot/ATV
Boat
RV
Other
What has you shopping for insurance today?
(Required)
Current Rates to High
Recently Moved
New Purchase
Unhappy With Previous Provider
Other
Other:
(Required)
Referred By Name
First
Last
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 long have you lived here / Owned the property?
How do you use the condo?
Primary Residence
Secondary Residence
Rental
Occupancy Status
Owner Occupied
Tenant Only Occupied
Vacant
Current Mailing 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
Is this quote for the same property as your current mailing address?
(Required)
Yes
No
Address of Property Being Quoted
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 Information
Current Insurer
Expiration Date
MM slash DD slash YYYY
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 Notes (Claim Details)
If you selected yes to previous claims please describe here.
Home Information Continued
Year Roof Updated
Roof Update Type
Partial
Full
Year Electrical Updated
Year Plumbing Updated?
Type of Air Conditioning
None
Central Air
Window Unit
Heating Type?
Is there a Basement?
Yes
No
Basement Status
Finished
Partially Finished
Unfinished
Foundation Type
Do you have a Mortgage?
Yes
No
Is it Escrowed?
Yes
No
Mortgage Company Name
Loan Number
Has home been non-renewed in past 3 years?
Yes
No
Additional Structures
Yes
No
Additional Structure Description
Auto Information
Total Drivers in Home
1
2
3
4
5
Total Vehicles in Home
1
2
3
4
5
Do you currently have auto insurance?
Yes
No
Have you previously had insurance?
Yes
No
Current Insurer
Policy Expiration Date
MM slash DD slash YYYY
When did your last policy expire?
MM slash DD slash YYYY
How much do you currently pay?
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
Vehicle #1
Vehicle Year
(Required)
Make
(Required)
Model
(Required)
VIN
Business Use
Yes
No
Rideshare or Delivery?
Yes
No
Rental Reimbursement?
Yes
No
Ownership
Leased
Financed
Owned
Level of Coverage Needed?
Liability Only
Full Coverage
If Vehicle leased or financed must have full coverage.
Vehicle #2
Vehicle Year
(Required)
Vehicle Make
(Required)
Vehicle Model
(Required)
VIN
Business Use
Yes
No
Rideshare or Delivery
Yes
No
Rental Reimbursement
Yes
No
Ownership
Leased
Financed
Owned
Level of Coverage Needed?
Liability Only
Full Coverage
If Vehicle leased or financed must have full coverage.
Vehicle #3
Vehicle Year
(Required)
Vehicle Make
(Required)
Vehicle Model
(Required)
VIN
Business Use
Yes
No
Rideshare or Delivery
Yes
No
Rental Reimbursement
Yes
No
Ownership
Leased
Financed
Owned
Level of Coverage Needed?
Liability Only
Full Coverage
If Vehicle leased or financed must have full coverage.
Vehicle #4
Vehicle Year
(Required)
Vehicle Make
(Required)
Vehicle Model
(Required)
VIN
Business Use
Yes
No
Rideshare or Delivery
Yes
No
Rental Reimbursement
Yes
No
Ownership
Leased
Financed
Owned
Level of Coverage Needed?
Liability Only
Full Coverage
If Vehicle leased or financed must have full coverage.
Vehicle #5
Vehicle Year
(Required)
Vehicle Make
(Required)
Vehicle Model
(Required)
VIN
Business Use
Yes
No
Rideshare or Delivery
Yes
No
Rental Reimbursement
Yes
No
Ownership
Leased
Financed
Owned
Level of Coverage Needed?
Liability Only
Full Coverage
If Vehicle leased or financed must have full coverage.
Tenant Only
What type of Property?
Single Family
2-3 Family
Other
Other
Vacant
Motorcycle/Slingshot/ATV
Name of Primary Driver
First
Last
Vehicle Type
(Required)
Motorcycle
Slingshot
ATV
Is Vehicle Used for Racing?
(Required)
Yes
No
Current Motorcycle License
Yes
No
Has Driver Completed Safety Course?
Yes
No
Year
(Required)
Make
(Required)
Model
(Required)
VIN
Umbrella
In order to purchase an umbrella liability policy you must have auto liability limits of at least 250/500/250 and home/renters personal liability of at least $300,000.
(Required)
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
Vacant Land
Business
Boat Information
Where is boat stored?
Primary Residence
Marina - Slip
Marina - Dry Stack
Other
Year
(Required)
Make
(Required)
Model
(Required)
Hull Number
Motor Type
(Required)
Inboard
Outboard
Top Speed (MPH)
Boat Length
(Required)
Boat is used for racing?
Yes
No
Do you own a boat trailer?
Yes
No
Recreational Vehicle
RV Type
5th Wheel
Motorcoach
Other
Year
(Required)
Make
(Required)
Model
(Required)
Please add any additional information here
Please upload current policy documents if you have them available.
Max. file size: 10 MB.
I agree that Sica Insurance may contact me via phone call, email and text message.
(Required)
Yes
No
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