External Intake

Step 1 of 24

Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Birth

Month

Day

Year

Drivers License

SSN

Occupation

Any tickets or accidents in the last 5 years?

Date

Description

Marital Status

Single

Married

Divorced

Widowed

Spouse Information

Spouse will be considered driver #2 if quoting auto.

Name

First Last

Phone

Any tickets or accidents in the last 5 years?

Date

Description

Drivers License #

Occupation

Date of Birth

Month

Day

Year

SSN

Current address or location of home to be insured(Required)

Street Address Address Line 2 City State ZIP Code

County

Years At Current Address

Mailing address different than location address?

Mailing Address

Street Address Address Line 2 City State ZIP Code

Years at current address

Prior Address

Street Address Address Line 2 City State ZIP Code

Purchase Date/Closing Date

Purchase Price

Driver #2

Name

First Last

Phone

Date of Birth

SSN

Drivers License

Relationship to you(Required)

Spouse

Child

Parent

Other

Occupation

Any tickets or accidents in the last 5 years?

Date

Description

Driver #3

Name(Required)

First Last

Phone

Date of Birth(Required)

Month

Day

Year

SSN

Drivers License

Relationship to you(Required)

Spouse

Child

Parent

Other

Occupation

Student

Yes

Good Student Disocunt (GPA)

Any tickets or accidents in the last 5 years?

Date

Description

Driver #4

Name(Required)

First Last

Phone

Date of Birth(Required)

SSN

Drivers License

Relationship to you(Required)

Spouse

Child

Parent

Other

Occupation

Student

Yes

Good Student Disocunt (GPA)

Any tickets or accidents in the last 5 years?

Date

Description

Driver #5

Name(Required)

First Last

Phone

Date of Birth(Required)

SSN

Drivers License

Relationship to you(Required)

Spouse

Child

Parent

Other

Occupation

Student

Yes

Good Student Disocunt (GPA)

Any tickets or accidents in the last 5 years?

Date

Description

Rental Property

Rental Property Address

Street Address Address Line 2 City State ZIP Code

County

Current Carrier

Personal Property Value

Occupany Status

Short-term rental? (VRBO, Air BnB, etc.)

Days rented per year

Year Built

Under Construction?

Square Feet

Stories

Construction Type

What type of siding?

Roof Type

Age of roof

Foundation

Garage

Garage Type

# of baths

Any unfinished areas in your home?

Please specify the unfinished area(s)

Floor Type

Wood %

Carpet %

Ceramic %

Vinyl %

Laminate %

OTHER (FILL IN)

Fireplace

Wood Burning Stove

Was this installed by a professional?

Central Heat/Air

Heat/Air Type?

Alarm

Smoke alarm

Dead bolt

Monitored fire & burglar alarm

Responding Fire Dept.

Miles to Fire Dept.

Animals

What kind of animals?

Trampoline

Trampoline Safety

Fenced

Netting

Swimming Pool

Pool Safety

Fenced

Locked

Condition of home

Motorcycle/ATV

Name of Primary Driver(Required)

First Last

Vehicle Type(Required)

Motorcycle

Slingshot

ATV

Is Vehicle Used for Racing?(Required)

Yes

Current Motorcycle License

Yes

Has Driver Completed Safety Course?

Yes

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.(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?(Required)

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

How many home/renters claims have you made in the last 5 years?(Required)

How many vehicles do you own?(Required)

Do you own any of the following items?(Required)

Boat/Yacht

Motorcycle

ATV

Golf Cart

Vacant Land

Business

Boat Information

Number of Watercraft looking to Insure:

Primary Operator

First Last

Years boating experience

Other Operator Information

Name

Date of Birth

Marital Status

List any operator in or outside the household with regular access to insured watercraft more than 12 times per year

HIN #

Year

Make

Model

Boat Value

Include value of permanent/portable boating equipment

Purchase Price

Year Purchased

Propulsion type

Inboard

Outboard

Inboard/Outboard

Jet

Non-powered

Number of engines

Boat Length

Hull material

Total horsepower

Excluding trolling and kicker motors

Maximum Speed

MPH

Enhanced performance modifications

Blowers, superchargers, etc.

Is boat used for racing?

Storage zip code

Where is boat stored?

Do you own a boat trailer?

Value of trailer

Year purchased

Multi-Owner

More than one owner, not in the same household

Prior Boat Insurance

Prior Carrier

Expiration date

Coverage Information

Hull Coverage (Comp & Collision)

Hull Deductible (Comp & Collision)

Liability coverage limit

Roadside Assistance

Uninsured/Underinsured Boater Coverage

Medical Payments Coverage

Fishing Equipment Coverage

Primary Personal Effects Coverage

Boat #2

Year

Make

Model

Boat Value

Include value of permanent/portable boating equipment

Purchase Price

Year Purchased

HIN #

Propulsion type

Inboard

Outboard

Inboard/Outboard

Jet

Non-powered

Number of engines

Boat Length

Hull material

Total horsepower

Excluding trolling and kicker motors

Maximum Speed

MPH

Enhanced performance modifications

Blowers, superchargers, etc.

Is boat used for racing?

Storage zip code

Where is boat stored?

Do you own a boat trailer?

Value of trailer

Year purchased

Multi-Owner

More than one owner, not in the same household

Prior Boat Insurance

Prior Carrier

Boat #3

Year

Make

Model

Boat Value

Include value of permanent/portable boating equipment

Purchase Price

Year Purchased

HIN #

Propulsion type

Inboard

Outboard

Inboard/Outboard

Jet

Non-powered

Number of engines

Boat Length

Hull material

Total horsepower

Excluding trolling and kicker motors

Maximum Speed

MPH

Enhanced performance modifications

Blowers, superchargers, etc.

Is boat used for racing?

Storage zip code

Where is boat stored?

Do you own a boat trailer?

Value of trailer

Year purchased

Multi-Owner

More than one owner, not in the same household

Prior Carrier

Prior Boat Insurance

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 upload current policy documents if you have them available.

Max. file size: 98 MB.

Consent(Required)

Extra Mile Insurance Solutions may contact me via phone call, email and text message.

I agree to the Extra Mile Insurance Solutions privacy policy https://www.extramileins.com/privacy-policy/ and I give Extra Mile Insurance Solutions permission to contact me by phone, email and text message.

CAPTCHA

Request Your Proposal Here

Are you ready to save time, aggravation, and money? The team at Extra Mile Insurance is here and ready to make the process as painless as possible. We look forward to meeting you!

Start Here

I have used an insurance broker for 5+ years, who were good at providing rates but were not overly adept at explaining options. I...

8 months ago

Jeremy Stone

I'm new to Extra Mile but so far they have provided great service and found affordable homeowner's and auto insurance for me. I've called a...

a year ago

Mark Leverett

Niki & staff were very courteous (considering I work overnights & they had to work with my schedule), professional & friendly. They worked hard to...

8 months ago

Angila Vandever

Allison and Extra Mile Insurance are fantastic to work with. We use them for our personal as well as for our small business. ...

a year ago

Patrice Walker

External Intake

Spouse Information

Flooring

Detatched Structure

Farming

Current Carrier Information

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

Vehicle #5

Driver #2

Driver #3

Driver #4

Driver #5

Current Auto Policy Information

Rental Property

Floor Type

Motorcycle/ATV

Umbrella

Boat Information

Coverage Information

Boat #2

Boat #3

Golf Cart

Recreational Vehicle

Would You Like Us To Review Your Policies?

Request Your Proposal Here