Personal Lines Intake Form

Step 1 of 21

Agent Completing This Form

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)

Drivers License(Required)

Date of Birth(Required)

MM slash DD slash YYYY

SSN

Occupation(Required)

Marital Status(Required)

Single

Married

Divorced

Widowed

Agent

Referred By Name

First Last

Current Address (No PO Boxes)(Required)

Street Address Address Line 2 City State ZIP Code

Address of Property Being Purchased(Required)

Same as current address

Street Address Address Line 2 City State ZIP Code

Would you like to add a different mailing address?(Required)

Yes

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Year Home Was Built(Required)

Purchase Date(Required)

MM slash DD slash YYYY

Sq Ft(Required)

Bedrooms

# of stories

1.5

Bathrooms

Garage

None

1 Car

2 Car

3 Car

4 Car

Additional Structures

Yes

Additional Structure Description

More than 5 acres?

Yes

Fireplace

Yes

Swimming Pool(Required)

Yes

Swimming Pool Enclosed/Fenced?(Required)

Yes

Diving Board or Slide?(Required)

Yes

Gated Community?(Required)

Yes, Passkey Gate Entrance

Yes, 24 Hour Manned Gate

None

Monitored Burglar/Fire Alarm?(Required)

Yes

Solar Panels(Required)

Yes

How Many Solar Panels?

Dog(s)?(Required)

Yes

Dog Breeds

If mixed please indicate type of mix.

Any bite history or security training?(Required)

Yes

Are you aware of any previous settlement or sinkhole issues on the property?(Required)

Yes

Have you had any home or renter's insurance claims in the past 5 years?(Required)

Yes

Exterior Material

Roof Material

Year Roof Updated

Year Electrical Updated

Year Plumbing Updated?

Year HVAC Updated

Dwelling

Loss of Use

Wind/Hail Deductible

All Other Perils Deductible

Other Structures

Personal Property

Liability

$100,000

$300,000

$500,000

Medical Payments

$5,000

Second Choice

Third Choice

Loan Amount

Closing Date

MM slash DD slash YYYY

Scheduled Personal Property

Artwork

Collectibles

Firearms

Jewelry

Technology

Other

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

Total Drivers in Home(Required)

Total Vehicles in Home(Required)

Liability Limits(Required)

$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(Required)

$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(Required)

Decline Comp

$100

$250

$500

$1,000

Collision Deductible(Required)

Decline Collision

$100

$250

$500

$1,000

Rental Reimbursement(Required)

Yes

Rental Reimbursement

$30/Day

$50/Day

PIP or Medical

Decline Both

PIP

Medical

PIP or Medical

$2,500

$5,000

$10,000

Vehicle Year

Make

Model

VIN

Business Use(Required)

Yes

Rideshare or Delivery?(Required)

Yes

Driver #2

Name(Required)

First Last

Phone

Date of Birth(Required)

MM slash DD slash YYYY

Drivers License

Occupation

Relationship to you(Required)

Spouse

Child

Parent

Other

Does this driver have a primary vehicle?(Required)

Yes

Vehicle used by Driver #2

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use(Required)

Yes

Rideshare or Delivery(Required)

Yes

Rental Reimbursement

Yes

Rental Reimbursement

$30/Day

$50/Day

Comprehensive Deductible

Decline Comp

$100

$250

$500

$1,000

Collision Deductible

Decline Collision

$100

$250

$500

$1,000

Name(Required)

First Last

Phone

Date of Birth(Required)

MM slash DD slash YYYY

Drivers License

Occupation

Relationship to you(Required)

Spouse

Child

Parent

Other

Does this driver have a primary vehicle?(Required)

Yes

Vehicle used by Driver #3

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use(Required)

Yes

Rideshare or Delivery(Required)

Yes

Rental Reimbursement

Yes

Rental Reimbursement

$30/Day

$50/Day

Comprehensive Deductible

Decline Comp

$100

$250

$500

$1,000

Collision Deductible

Decline Collision

$100

$250

$500

$1,000

Name(Required)

First Last

Phone

Date of Birth(Required)

MM slash DD slash YYYY

Drivers License

Occupation

Relationship to you(Required)

Spouse

Child

Parent

Other

Does this driver have a primary vehicle?(Required)

Yes

Vehicle used by Driver #4

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use(Required)

Yes

Rideshare or Delivery(Required)

Yes

Rental Reimbursement

Yes

Rental Reimbursement

$30/Day

$50/Day

Comprehensive Deductible

No Comp

$100

$250

$500

$1,000

Collision Deductible

No Collision

$100

$250

$500

$1,000

Name(Required)

First Last

Phone

Date of Birth(Required)

MM slash DD slash YYYY

Drivers License

Occupation

Relationship to you(Required)

Spouse

Child

Parent

Other

Does this driver have a primary vehicle?(Required)

Yes

Vehicle used by driver #5

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use(Required)

Yes

Rideshare or Delivery(Required)

Yes

Rental Reimbursement

Yes

Rental Reimbursement

$30/Day

$50/Day

Comprehensive Deductible

No Comp

$100

$250

$500

$1,000

Collison Deductible

No Collision

$100

$250

$500

$1,000

Investment Property

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

Motorcycle/Slingshot/ATV

Name of Primary Driver(Required)

First Last

Vehicle Type(Required)

Motorcycle

Slingshot

ATV

Is Vehicle Used for Racing?(Required)

Yes

Current Motorcycle License(Required)

Yes

Has Driver Completed Safety Course?(Required)

Yes

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 $250,000/$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)

How many auto claims have you made in the last 5 years?(Required)

Any drivers on your auto policy have an at-fault accident in the last 5 years?(Required)

Yes

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

Boat/Yacht

Motorcycle

ATV

Golf Cart

Vacant Land

Business

Boat Information

Where is boat stored?(Required)

Primary Residence

Marina - Slip

Marina - Dry Stack

Other

Year(Required)

Make(Required)

Model(Required)

Hull Number

Motor Type(Required)

Inboard

Outboard

Top Speed (MPH)(Required)

Boat Length(Required)

Boat is used for racing?(Required)

Yes

Do you own a boat trailer?(Required)

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: 300 MB.

Consent

Reliant Insurance Services may contact me via phone call, email and text message.

This field is for validation purposes and should be left unchanged.

Personal Lines Intake Form

Driver #2

Vehicle used by Driver #2

Vehicle used by Driver #3

Vehicle used by Driver #4

Vehicle used by driver #5

Investment Property

Motorcycle/Slingshot/ATV

Umbrella

Boat Information

Golf Cart

Recreational Vehicle

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