PL Intake - Garcia Insurance Services

If you have replaced your roof within the last 5 years please send PAID receipt for installation or a statement from a licensed roofer showing installation date/estimated age of roof to documents@gisnola.com

Personal Lines Intake Form

Step 1 of 14

Primary Insured Information

Name

First Last

Phone

Driver License

Date of Birth

MM slash DD slash YYYY

SSN

Occupation

Marital Status

Single

Married

Divorced

Widowed

Education

High School

Associate Degree

Bachelor's Degree

Graduate or Professional Degree

Some College

Spouse Information

Spouse Name

First Last

Spouse Phone

Spouse Email

Spouse Birth Date

MM slash DD slash YYYY

Spouse Driver License

Spouse Occupation

Spouse Education

High School

Associate Degree

Bachelor's Degree

Graduate or Professional Degree

Some College

How did you hear about us?

Current Client

Mortgage Referral

Realtor Referral

Financial Advisor Referral

Other Referral

Facebook

Google

Instagram

Other

Referred By Name

First Last

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

Auto

Home

Condo

Umbrella

Investment Property

Motorcycle/Slingshot/ATV

Golf Cart

Boat

Flood

Other

What other type of insurance can we quote for you?

New purchase or already own the condo/home?

New Purchase

Already Own

Expected Closing Date

MM slash DD slash YYYY

How do you use the condo?

Primary Residence

Secondary Residence

Rental

Current Address (No PO Boxes)

Street Address Address Line 2 City State ZIP Code

Address of Property Being Purchased

Same as current address

Street Address Address Line 2 City State ZIP Code

Would you like to add a different mailing address?

Yes

Mailing Address

Street Address Address Line 2 City State ZIP Code

Home/Condo Information

Year Home Was Built

Purchase Date

MM slash DD slash YYYY

Sq Ft

Bedrooms

# of stories

1.5

Bathrooms

Garage

None

1 Car

2 Car

3 Car

4 Car

Garage Type

Additional Structures

Yes

Additional Structure Description

More than 5 acres?

Yes

Fireplace

Yes

Wood-burning stove?

Yes

Central air conditioning?

Yes

Swimming Pool

Yes

Swimming Pool Enclosed/Fenced?

Yes

Diving Board or Slide?

Yes

Circuit Breakers or Fuses?

Yes

Burglar bars on the windows?

Yes

Are they quick release?

Yes

Gated Community?

Yes, Passkey Gate Entrance

Yes, 24 Hour Manned Gate

None

Monitored Burglar Alarm?

Yes

Monitored Fire Alarm?

Yes

Please upload a current alarm certificate to apply any discounts.

Max. file size: 98 MB.

Solar Panels

Yes

How Many Solar Panels?

Dog(s)?

Yes

Dog Breeds

If mixed please indicate type of mix.

Any bite history or security training?

Yes

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

Yes

Is property located in a historic district or on a historic registry?

Yes

Have you filed for a claim?

Yes

Has all damage been repaired?

Yes

Are all claims closed?

Yes

Roof Shape

Roof Material

Exterior Material

Year Roof Updated

Year Electrical Updated

Year Plumbing Updated?

Year HVAC Updated

Dwelling

Type of Dwelling

Foundation

Loss of Use

Wind/Hail Deductible

All Other Perils Deductible

Do you have a covered porch/patio?

Yes

if so, estimated square footage

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)

Item Description

Replacement Value

Purchase Date

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

Home Notes

Auto Information

Total Drivers in Home

Total Vehicles in Home

Driver Name

First Last

Phone

Date of Birth

MM slash DD slash YYYY

Driver's License

What is the 17 Character VIN# of your vehicle?

Please double check your entry to make sure it's correct. Also note VINs never contain the letters L or O (if you see them they are 1 or 0).

It is used for?

Pleasure

Work/School Commute

Business/Commercial (Including Uber and Lyft)

How many miles will this vehicle be driven annually?

The average commuter will drive approximately 13,000 miles a year.

What is the odometer of your vehicle?

What date did you purchase the vehicle?

MM slash DD slash YYYY

Does your vehicle need Comprehensive & Collision Coverage?

Yes

Is there a lien holder? If so, who?

If there is none, please input "None"

Driver #2

Name

First Last

Phone

Date of Birth

MM slash DD slash YYYY

Drivers License

Occupation

Relationship to you

Spouse

Child

Parent

Other

Driver #3

Name

First Last

Phone

Date of Birth

MM slash DD slash YYYY

Drivers License

Occupation

Relationship to you

Spouse

Child

Parent

Other

Driver #4

Name

First Last

Phone

Date of Birth

MM slash DD slash YYYY

Drivers License

Occupation

Relationship to you

Spouse

Child

Parent

Other

Driver #5

Name

First Last

Phone

Date of Birth

MM slash DD slash YYYY

Drivers License

Occupation

Relationship to you

Spouse

Child

Parent

Other

Auto Coverage Info

Note: This section is for coverage amounts and is plainly optional.

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

Rental Reimbursement

$30/Day

$50/Day

PIP or Medical

Decline Both

PIP

Medical

PIP or Medical

$2,500

$5,000

$10,000

Vehicle #1

Vehicle Year

Make

Model

VIN

Business Use

Yes

Rideshare or Delivery?

Yes

Vehicle #2

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

Rideshare or Delivery

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

Vehicle #3

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

Rideshare or Delivery

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

Vehicle #4

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

Rideshare or Delivery

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

Vehicle #5

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

Rideshare or Delivery

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

Street Address Address Line 2 City State ZIP Code

Property Status

Currently Occupied with Tenants

Listed For Sale - No Occupants

Listed For Rent - No Occupants

Undergoing Renovations - Vacant

Year Home Was Built

Purchase Date

MM slash DD slash YYYY

Sq Ft

Bedrooms

# of stories

1.5

Bathrooms

Garage

None

1 Car

2 Car

3 Car

4 Car

Garage Type

Additional Structures

Yes

Additional Structure Description

More than 5 acres?

Yes

Fireplace

Yes

Wood-burning stove?

Yes

Central air conditioning?

Yes

Swimming Pool

Yes

Swimming Pool Enclosed/Fenced?

Yes

Diving Board or Slide?

Yes

Circuit Breakers or Fuses?

Yes

Burglar bars on the windows?

Yes

Are they quick release?

Yes

Gated Community?

Yes, Passkey Gate Entrance

Yes, 24 Hour Manned Gate

None

Monitored Burglar Alarm?

Yes

Monitored Fire Alarm?

Yes

Please upload a current alarm certificate to apply any discounts.

Max. file size: 98 MB.

Solar Panels

Yes

How Many Solar Panels?

Is property located in a historic district or on a historic registry?

Yes

Roof Shape

Roof Material

Exterior Material

Year Roof Updated

Year Electrical Updated

Year Plumbing Updated?

Year HVAC Updated

Dwelling

Type of Dwelling

Foundation

Loss of Use

Wind/Hail Deductible

All Other Perils Deductible

Do you have a covered porch/patio?

Yes

if so, estimated square footage

Other Structures

Personal Property

Home Notes

Motorcycle/Slingshot/ATV

Name of Primary Driver

First Last

Vehicle Type

Motorcycle

Slingshot

ATV

Is Vehicle Used for Racing?

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.

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

Do you own any of the following items?

Boat/Yacht

Motorcycle

ATV

Golf Cart

Vacant Land

Business

Boat Information

Where is boat stored?

Primary Residence

Marina - Slip

Marina - Dry Stack

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

Flood Information

Do you currently have flood insurance?

Is your property in a flood zone?

Property Type

Primary Home

Secondary Home

Rental Property

Other

Other Property

Address(Required)

Street Address Address Line 2 City State ZIP Code

Foundation

Number of Detached Structures

Shed, Pool House, Barn, etc.

Is There An Elevator

How Many Stories

Please upload current policy documents if you have them available.

Max. file size: 98 MB.

Consent(Required)

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

CAPTCHA