Personal Lines Intake Form Commercial Lines Intake Form Personal Lines Intake Form Step 1 of 17 5% Primary Insured InformationName First Last PhoneEmail Drivers License Date of Birth MM slash DD slash YYYY Occupation Marital Status Single Married Divorced Widowed Education High School Associate Degree Bachelor's Degree Graduate or Professional Degree Some College Spouse InformationSpouse Name First Last Spouse PhoneSpouse Email Spouse Birth Date MM slash DD slash YYYY Spouse Drivers License Spouse Education High School Associate Degree Bachelor's Degree Graduate or Professional Degree Some College Spouse Occupation How did you hear about Republix? Client Referral Mortgage Referral Realtor Referral Financial Advisor Referral Other Referral Facebook Google Instagram Other Referred By Name First Last Preferred AdvisorColnn MiguelgorryChris MarshWhat type of insurance can we quote for you? 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 property? New Purchase Already Own How do you use the property? Primary Residence Secondary Residence Rental Current Address (No PO Boxes) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address of Property Being Purchased Same as current address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Would you like to add a different mailing address? Yes No Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Property InformationNumber of Adults Living in Home12345+Number of Children Living in Home12345+Year BuiltPurchase/Closing Date MM slash DD slash YYYY Sq FtBedrooms 1 2 3 4 5 # of stories 1 1.5 2 Bathrooms11.522.533.544.5Garage None 1 Car 2 Car 3 Car 4 Car Additional Structures Yes No Additional Structure Description More than 5 acres? Yes No Fireplace Yes No Swimming Pool(Required) Yes No Swimming Pool Enclosed/Fenced?(Required) Yes No Diving Board or Slide?(Required) Yes No Trampoline(Required) Yes No Trampoline Has Net?(Required) Yes No Gated Community? Yes, Passkey Gate Entrance Yes, 24 Hour Manned Gate None Monitored Burglar/Fire Alarm? Yes No Solar Panels Yes No How Many Solar Panels? Add RemoveDog(s)?(Required) Yes No Dog Breeds Add RemoveIf mixed please indicate type of mix.Any bite history or security training?(Required) Yes No Are you aware of any previous settlement or sinkhole issues on the property?(Required) Yes No Have you had any home or renter's insurance claims in the past 5 years?(Required) Yes No Home Information ContinuedExterior MaterialBrick VeneerClapboardVinyl SidingStone VeneerStuccoRoof MaterialComposite ShinglesAsphalt ShinglesArchitectural ShinglesMetalTileYear Roof UpdatedYear Electrical UpdatedYear Plumbing Updated?Year HVAC UpdatedDwellingLoss of UseWind/Hail Deductible All Other Perils Deductible Other StructuresPersonal PropertyLiability $100,000 $300,000 $500,000 Medical Payments $5,000 Second Choice Third Choice Loan AmountScheduled Personal Property Artwork Collectibles Firearms Jewelry Technology Other Valuable Items List (Click the + to add additional items)Item DescriptionReplacement ValuePurchase Date Add RemovePlease list each item and include an appraised/estimated value. Only one item per row please.Home Notes Auto InformationTotal Drivers in Home(Required) 1 2 3 4 5 Total Vehicles in Home(Required) 1 2 3 4 5 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 PIP Decline Both PIP Medical Medical $2,500 $5,000 $10,000 ListYearMakeModelVIN Add RemoveVehicle Use(Required) Commute Pleasure Business Rideshare Delivery Which vehicle(s) is used for business? Which vehicle(s) is used for rideshare? Which vehicle(s) is used for delivery? Driver #2Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers License Occupation Relationship to you Spouse Child Parent Other Driver #3Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers License Occupation Relationship to you Spouse Child Parent Other Driver #4Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers License Occupation Relationship to you Spouse Child Parent Other Driver #5Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers License Occupation Relationship to you Spouse Child Parent Other Investment PropertyAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed 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/ATVName 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 UmbrellaIn 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.(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 Golf Cart Vacant Land Business Boat InformationWhere is boat stored? Primary Residence Marina - Slip Marina - Dry Stack Other Year Make Model Hull Number Motor Type Inboard Outboard Top Speed (MPH)Boat LengthBoat is used for racing? Yes No Do you own a boat trailer? Yes No Golf CartYear Make Model Primary Use Transportation Golfing Fuel Type Electric Gas Recreational VehicleRV Type 5th Wheel Motorcoach Other Year Make Model Please upload current policy documents if you have them available.Max. file size: 98 MB.Consent(Required) Republix Risk Mitigation Insurance Solutions may contact me via phone call, email and text message. Commercial Lines Intake Form "*" indicates required fields Business DetailsBusiness Name:* Name of person completing this form First Last Business Entity:* FEIN / Tax-ID Number: Phone Number:*Email:* Mailing Address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is Physical Address Same As Mailing Address?* Yes No Physical Address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website Address: Effective Date: MM slash DD slash YYYY Are You A Contractor?* Yes No Brief Description of Operations:Names and % of Ownership for all Officers:*Full NamePosition% of Ownership Add RemoveYear Business Started: Number of Employees:Estimated Annual Payroll:Estimated Annual Revenue:Additional Contractor DetailsContractors License # % of work Subcontracted out % of Residential Work % of Commercial Work % of Remodel/Install work % of New Construction Work % of Service/Maintenance Work Do you perform Government/Municipality Work?YesNo
