Intake Forms

Personal Lines Intake Form Commercial Lines Intake Form

Personal Lines Intake Form

Step 1 of 17

Primary Insured Information

Name

First Last

Phone

Drivers License

Date of Birth

MM slash DD slash YYYY

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 Drivers License

Spouse Education

High School

Associate Degree

Bachelor's Degree

Graduate or Professional Degree

Some College

Spouse Occupation

How did you hear about Republix?

Client Referral

Mortgage Referral

Realtor Referral

Financial Advisor Referral

Other Referral

Facebook

Google

Instagram

Other

Referred By Name

First Last

Preferred Advisor

What type of insurance can we quote for you?

Auto

Home

Condo

Umbrella

Investment Property

Motorcycle/Slingshot/ATV

Golf Cart

Boat

Other

What other type of insurance can we quote for you?

New purchase or already own the property?

New Purchase

Already Own

How do you use the property?

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

Property Information

Number of Adults Living in Home

Number of Children Living in Home

Year Built

Purchase/Closing Date

MM slash DD slash YYYY

Sq Ft

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

Trampoline(Required)

Yes

Trampoline Has Net?(Required)

Yes

Gated Community?

Yes, Passkey Gate Entrance

Yes, 24 Hour Manned Gate

None

Monitored Burglar/Fire Alarm?

Yes

Solar Panels

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

Home Information Continued

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

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(Required)

Total Vehicles in Home(Required)

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

PIP

Decline Both

PIP

Medical

$2,500

$5,000

$10,000

List

Year

Make

Model

VIN

Vehicle Use(Required)

Commute

Pleasure

Business

Rideshare

Delivery

Which vehicle(s) is used for business?

Which vehicle(s) is used for rideshare?

Which vehicle(s) is used for delivery?

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

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

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.(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?

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

Please upload current policy documents if you have them available.

Max. file size: 5 MB.

Consent(Required)

Republix Risk Mitigation Insurance Solutions may contact me via phone call, email and text message.

Commercial Lines Intake Form

"*" indicates required fields

Business Details

Business Name:*

Business Entity:*

FEIN / Tax-ID Number:

Phone Number:*

Email:*

Mailing Address:*

Street Address City State ZIP Code

Is Physical Address Same As Mailing Address?*

Yes

Physical Address:*

Street Address City State ZIP Code

Website Address:

Effective Date:

MM slash DD slash YYYY

Are You A Contractor?*

Yes

Brief Description of Operations:

Names and % of Ownership for all Officers:*

Full Name

Position

% of Ownership

Year Business Started:

Number of Employees:

Estimated Annual Payroll:

Estimated Annual Revenue:

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?