Intake Form

Please provide the following information.

Policy & Coverage Details

• Current policy documents (full declarations page, endorsements, and coverage limits)

• Type of policy (auto, home, renters, life, business, etc.)

• Coverage amounts (liability, collision, comprehensive, UM/UIM, deductibles, etc.)

• Special add-ons (roadside, rental reimbursement, flood, umbrella, etc.)

• Effective & expiration dates of current policy

Personal / Business Risk Profile

• For Auto:

  • Driver info (age, license number, driving history)

  • Vehicle details (VIN, year, make, model, mileage, usage type)

  • Any tickets/accidents/claims in the last 5 years

• For Home:

  • Property details (year built, square footage, roof age, safety features, replacement cost)

  • Claims history

• For Life/Health:

  • Age, gender, tobacco use, health conditions, coverage need (income replacement, mortgage protection, etc.)

Financial & Coverage Goals

• Budget target or ideal price range

• Desired deductible amount

• Priorities (lowest price, best coverage, specific protections)

• Pain points (e.g., “too high premium,” “I don’t understand the fine print,” “not sure if I’m over-insured”)