Forms - Extra Mile Insurance Solutions

PL Intake CL Intake Boat Form Rental Form Commercial Property GL

PL Intake

Step 1 of 22

Assigned Advisor

How did you hear about us?

Who Referred You?

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

Auto

Home

Condo

Umbrella

Investment 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

MM slash DD slash YYYY

Drivers License

SSN

Occupation

Marital Status

Single

Married

Divorced

Widowed

Spouse Information

Spouse will be considered driver #2 if quoting auto.

Name

First Last

Phone

Date of Birth

MM slash DD slash YYYY

SSN

Phone

Current Address (location of home to be insured)(Required)

Street Address Address Line 2 City State ZIP Code

Current 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

MM slash DD slash YYYY

Year Home Was Built

Property Type

Sq Ft

Foundation

Finished Basement %

Frame Detail

# of stories

1.5

Bathrooms

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

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)

Yes

Alarm Company

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?(Required)

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)

Med Pay

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

Rental Reimbursement

Yes

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

Rental Reimbursement

Yes

Vehicle #3

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

Rideshare or Delivery(Required)

Yes

Rental Reimbursement

Yes

Rental Reimbursement

$30/Day

$50/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

Rental Reimbursement

Yes

Rental Reimbursement

$30/Day

$50/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

Yes

Rideshare or Delivery(Required)

Yes

Rental Reimbursement

Yes

Rental Reimbursement

$30/Day

$50/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)

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 #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

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

Any tickets or accidents in the last 5 years?

Date

Description

Current Auto Policy Information

Liability Limits

$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

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

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

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

Decline

Current Auto Insurer Name

First Last

Current Policy Expiration Date

MM slash DD slash YYYY

Length of Time with Current Auto Insurer

Current Towing Limit?

Current Rental Car Reimbursement Limit?

Current Monthly Auto Premium

Pay Plan Preferred

Dwelling Fire Policy

Address(Required)

Street Address Address Line 2 City State ZIP Code

Property Status(Required)

Currently Occupied with Tenants

Listed For Sale - No Occupants

Listed For Rent - No Occupants

Undergoing Renovations - Vacant

Untitled

First Choice

Second Choice

Third Choice

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

Where is boat stored?

Primary Residence

Marina - Slip

Other

Year

Make

Model

Hull Number

Motor Type

Inboard

Outboard

Top Speed (MPH)

Boat Length

Boat is used for racing?

Yes

Do you own a boat trailer?

Yes

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.

CL Intake

"*" indicates required fields

Step 1 of 3

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Business Details

Assigned Advisor

How did you hear about us?

Internal Referral Sources

Who Referred you?

Business Name:*

Business Website:

Business Entity

FEIN / Tax-ID Number or Social Security Number*

Phone Number:*

Email:*

Names and % of Ownership for all Officers:*

Full Name

Position

% of Ownership

Mailing Address:*

Street Address City State ZIP Code

Is Physical Address Same As Mailing Address?*

Yes

Location Address:*

Street Address City State ZIP Code

Years of Experience

Requested Effective Date:

MM slash DD slash YYYY

Year Business Started:

Coverage(s) Needed*

Business Auto

Building/Property

Cyber Liability

General Liability

Workers Comp

Are You A Contractor?*

Yes

Do you use multi-factor authentication?*

Yes

Brief Description of Operations:*

Number of Full-Time Employees:

Number of Part-Time Employees:

Estimated Annual Payroll:

Estimated Gross Annual Revenue/Sales:*

Amount of Liability Coverage*

Amount of Business Contents/Property Coverage*

Additional Contractor Details

Contractors 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?

Tools/Equipment coverage needed?

Any items valued over $5,000

List

Item Description

Value

Business Auto Information

List all drivers

Name

Date of birth

Driver's License

List all vehicles

Year

Make

Model

Building/Property

Value of Building

Value of Personal Contents

Do you have multiple locations?

List locations

Street Address

City

State

Zip

Owner/Tenant

Date Purchased/Leased

% of building occupied

% of leased to others

Type of business occupies the space?

Year building originally built

Building foundation type

Building type

Building siding type

Stories

Total square feet

Roof age

Roof Type

Wiring age

Plumbing age

Heating age

Sprinkler system?

Is there an active premises alarm?

Is there a safe or vault?

How often do you make cash deposits?

Need sign coverage?

Amount of sign coverage

Notes

Boat Form

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Customer Information

Full Name:

First Last

Gender

Date of Birth::

MM slash DD slash YYYY

Social Security Number:

Mailing Address:

Street Address Address Line 2 City State ZIP Code

Email Address:

Phone Number:

Work:

Marital Status:

Years Boating Experience:

AF/NAF Auto and Boat/PWC Accidents, and or Comprehensive Claims over $1,000:

Driver License #

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

Purchase Year:

Watercraft Information

Type (i.e., pleasure, fishing, sail, etc.):

Year:

Make:

Model:

Length:

HIN #:

Number of Engines:

Total Horsepower (excluding trolling and kicker motors):

Propulsion Type:

Inboard

Outboard

Inboard/Outboard

Jet

Non-Powered

Hull Material:

Maximum Speed:

Enhanced Performance Modifications (i.e., blowers, superchargers, etc.):

Trailer Coverage:

Yes

Purchase Year:

Boat Value (Include Value of Permanent / portable boating equipment.)

Value of Trailer?

Where is boat stored during boating season:

Purchase Price

Underwriting/Discount Information

Primary Residence:

Own a Home/Condo

Own a Manufactured Home (10 years old or newer)

Rent

Live with Parents

Other

Please specify:

Association Name:

None

USCG Auxiliary

US Power Squadron

USAA

Dockage/Mooring/Storage ZIP Code:

Watercraft Use (i.e., pleasure, business, etc.):

Multi-Owner (more than one owner, not in the same household):

Yes

Discounts:

Homeowner

Multi-Policy

Original Owner

Safety Course

Transfer

Prior Boat Insurance:

Yes

Prior Carrier:

Expiration Date

Coverage Information

Hull Coverage (Comp & Collision):

Total Loss Replacement (new boats only)

Agreed Value

Actual Cash Value

Hull Deductibles (Comp & Collision):

$250

$500

$1,000

$2,500

$5,000

Liability Coverage Limits:

Roadside Assistance:

Yes

Uninsured/Underinsured Boater Coverage:

Yes

Medical Payments Coverage:

$1,000

$2,500

$5,000

$7,500

$10,000

$25,000

Fishing Equipment Coverage (Primary):

$1,000

$2,500

$5,000

$10,000

Primary Personal Effects Coverage:

$1,000

$2,000

$3,000

$4,000

$5,000

Untitled

Rental Form

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Contact Information

Name

First Last

Rental Dwelling Information

Physical Address of Home:

Street Address Address Line 2 City State ZIP Code

Mailing Address:

Street Address Address Line 2 City State ZIP Code

County:

Short term rental? (Air Bnb):

Yes

Occupancy:

Owner

Tenant

Both

How Many Days a Year?

Personal Property coverage requested? (contents)

Year of Construction:

Under construction?

Yes

Stories:

1 ½

Stories:

Frame

Masonry

Fire Resistive

If Frame, what type of siding:

Wood

Vinyl

Age of roof:

Type of roof:

Comp Shingles

Wood

Metal

Clay

Foundation:

Slab

Crawlspace

Garages:

1 ½ c

Garages:

Detached

Attached

# of Baths:

Any unfinished areas on your home?

Yes

Please specify the unfinished area.

Floors:

Wood

Tile

Vinyl

Carpet

Fireplace:

Yes

Please specify:

Gas

Wood

Wood Stove:

Yes

Installed by a professional?

Yes

Central Heat/Air:

Yes

Heat/Air Type?

Alarm:

Smoke Alarm

Dead Bolts

Monitored Fire & Burglar Alarm

Responding Fire Dept:

Miles to Fire Dept:

PC:

Animals:

Yes

What kind? Please specify.

Trampoline:

Yes

Please specify:

Fenced

Netting

Swimming pool:

Yes

Please specify:

Fenced

Locked

Condition of Home:

Excellent

Very Good

Good

Poor

Commercial Property

Location Address:

Street Address Address Line 2 City State ZIP Code

Do You Have Multiple Locations?

Yes

List Other Properties

Effective Date:

MM slash DD slash YYYY

Interest in Building:

Date Purchased?

% of building occupied:

% leased to others:

Select Occupany

Residential

Commercial

What type of Business will occupy the space?

Year Building Originally Built?

Building originally built:

Building Type

If frame what type of siding?

Stories

Total Square Feet:

Roof Age:

Roof Type

Age of Wiring:

Plumbing:

Heating:

Sprinkler System

Need Sign Coverage:

Yes

Need Sign Coverage:

Amount of Coverage

Is there a Premises Alarm Active?

Is there a Safe or Vault?

How often does applicant make a deposit of cash?

Value of Building:

Value of Personal Contents:

Coverage requested:

Untitled

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Business Contact Name:

Email:

Phone:

Name of Business:

Fed ID or SS#:

Mailing Address:

Street Address Address Line 2 City State ZIP Code

Location Address:

Street Address Address Line 2 City State ZIP Code

Business Entity Type:

Requested Effective Date:

MM slash DD slash YYYY

Year Business Started:

Years of Experience:

Experience Type:

Number of active owners or partners:

Annual Gross Revenue/Sales:

Number of Employees (Full time):

Number of Employees (Part time):

Annual Payroll:

Any additional Insureds or Certificates required?

Please state the full name and address of additional Insured.

% of Commercial Business (if contractor):

% of Residential Business (if contractor):

Insured Tools/Equipment coverage needed:

How much coverage? Any items valued over $5000, please list separately.

Coverage requested for:

Additional information needed, please state.

Amount of Coverage for Liability requested:

Amount of Coverage for business contents/property:

Please provide a short description of business operations:

Commercial Auto Information

Drivers

Name

DOB

DL #

Vehicles

Year

Make

Model

Vin

Comprehensive Deductible

Collision Deductible