External Intake

Step 1 of 24

Assigned Advisor

How did you hear about us?

Internal Referral Sources

Who Referred You?

What type of insurance can we quote for you?(Required)

Auto

Home

Condo

Umbrella

Rental Property

Motorcycle/Slingshot/ATV

Golf Cart

Boat

Other

What other type of insurance can we quote for you?(Required)

New purchase or already own the condo/home?(Required)

New Purchase

Already Own

How do you use the condo?(Required)

Primary Residence

Secondary Residence

Rental

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

Month

Day

Year

Purchase Price

Year Home Was Built

Property Type

Sq Ft

Foundation

Finished Basement %

Frame Detail

# of stories

1.5

Bathrooms

Flooring

Wood %

Carpet %

Cermaic %

Vinyl %

Laminate %

OTHER (FILL IN)

Roof Material

Roof Shape

Year Roof Updated

Any updates to heating, electrical or plumbing?

Heating

Electrical

Plumbing

Year Heating Updated

Type of Update

Year Electrical Updated

Type of Update

Year Plumbing Updated?

Type of Update

Garage

Yes Attached

Yes Detached

Car Port

None

Garage

1 Car

2 Car

3 Car

4 Car

Detached Structures

Yes

Detatched Structure

Year Built open box

What Type?

What Type?(Required)

Detached Structure Sq. Footage

Detatched Building Exterior

Other Exterior Material

Detatched Roof Type

Other Roof Type(Required)

Detatched Building Roof Age

Detached Structures Used For Farming Purposes?

Yes

Which building and how is it used?(Required)

More than 5 acres?

Yes

Fireplace

Yes - Gas

Yes - Wood

Woodstove

Yes

Deck/Patio

Yes - Covered

Yes - Screened

Yes - Enclosed

Sq. Footage

Swimming Pool(Required)

Yes

Swimming Pool Fenced and Locked?(Required)

Yes

Diving Board or Slide?(Required)

Yes

Trampoline(Required)

Yes

Trampoline Has A Net?(Required)

Yes

Monitored Burglar/Fire Alarm?(Required)

Local

Monitored

None

Monitored Alarm Company Name

Responding Fire Department?

Miles to Fire Department?

Paid Fire Subscription Required?

Yes

Unknown

Fire Protection Class

Any Pets?

Dog Breeds

If mixed please indicate type of mix.

Any bite history or security training?

Yes

Any Horses?

Yes

How Many?(Required)

Any Cattle?

Yes

How Many?(Required)

Any Other Livestock?

Yes

Types of Livestock

Livestock

How Many

Farming Operations?

Yes

Scheduled Personal Property

Jewelry

Furs

Firearms

Art

Cameras

Musical Instruments

Other

Total Value of Jewelry Owned?

Total Value of Firearms Owned?

Total Value of Art/Cameras/Furs/Musical Instruments Owned?

Valuable Items List (Click the + to add additional items)

Please list each item and include an appraised/estimated value. Only one item per row please.

Home Notes

Farming

Farming Type

Annual Farming Income

Current Carrier Information

Current Carrier

Policy Expiration

MM slash DD slash YYYY

Dwelling Limit

Personal Property Limit

Liability Limit

Deductible

Current Premium

Escrowed

Yes

Mortgage Company

Have there been any home claims in the last 5 years?

Yes

Claims

Include Date of claim, Type of claim (wind/hail/water/lightning/other), Amount paid.

Total Drivers in Home(Required)

Total Vehicles in Home(Required)

Vehicle #1

Vehicle Year

Make

Model

VIN

Comprehensive Deductible

$500

$1,000

Decline Comp

Collision Deductible

$500

$1,000

Decline Comp

Business Use

Yes

Rideshare or Delivery?(Required)

Yes

Roadside

Yes

Decline

Rental Reimbursement

Decline

$50/Day

$75/Day

$100/Day

Vehicle #2

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Comprehensive Deductible

$500

$1,000

Decline Comp

Collision Deductible

$500

$1,000

Decline Comp

Business Use(Required)

Yes

Rideshare or Delivery(Required)

Yes

Roadside

Yes

Decline

Rental Reimbursement

Decline

$50/Day

$75/Day

$100/Day

Vehicle #3

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

Rideshare or Delivery(Required)

Yes

Roadside

Yes

Decline

Rental Reimbursement

Decline

$50/Day

$75/Day

$100/Day

Comprehensive Deductible

$500

$1,000

Decline Comp

Collision Deductible

$500

$1,000

Decline Comp

Vehicle #4

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

Rideshare or Delivery(Required)

Yes

Roadside

Yes

Decline

Rental Reimbursement

Decline

$50/Day

$75/Day

$100/Day

Comprehensive Deductible

$500

$1,000

Decline Comp

Collision Deductible

$500

$1,000

Decline Comp

Vehicle #5

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use(Required)

Yes

Rideshare or Delivery(Required)

Yes

Roadside

Yes

Rental Reimbursement

$50/Day

$75/Day

$100/Day

Comprehensive Deductible

$500

$1,000

Decline Comp

Collison Deductible

$500

$1,000

Decline Comp

Driver #2

Name

First Last

Phone

Date of Birth

MM slash DD slash YYYY

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)

MM slash DD slash YYYY

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)

MM slash DD slash YYYY

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

Current Auto Policy Information

Liability Limits

$25,000/$50,000/$25,000

$50,000/$100,000/$50,000

$100,000/$300,000/$100,000

$250,000/$500,000/$250,000

$500,000/$500,000/$500,000

UM/UIM

$25,000/$50,000/$25,000

$50,000/$100,000/$50,000

$100,000/$300,000/$100,000

$250,000/$500,000/$250,000

Decline

Do you currently have Gap Coverage?

Yes

Current Auto Insurer Name

Current Policy Expiration Date

MM slash DD slash YYYY

Length of Time with Current Auto Insurer

Towing Reimbursement

Yes

Decline

Rental Reimbursement

Yes

Decline

Current Monthly Auto Premium

Pay Plan Preferred

Med Pay

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

Month

Day

Year

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)

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Extra Mile Insurance Solutions really worked with me when searching for car & residential insurance. Niki was honest about how my current coverage wasn't meeting...

a month ago

Jennifer Ford

I found Extra Mile by a Google search, after several weeks of insurance shopping. I was relieved that Niki was able to find better rates...

a month ago

Mary M

I was very pleased that Niki Henley took the time and searched for us a better rate on our auto and home insurance. She was...

a month ago

Amanda Webb

Very nice and professional. Niki and Natalie were a huge help. Just joined this company last week. They were 150 cheaper a month than last...

2 weeks ago

R S

Niki was super helpful and was able to get us a great rate for our home insurance! Give Extra Mile Insurance Solutions a call today!

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