Auto Client

Information Worksheet
Term

Effective Date ___________________

q 6 months

q 12 months

Primary Named Insured Information

Name _____________________________________________________________________________________________

Address___________________________________ City _____________________ State_____ ZIP__________

SS#______________________________________ DOB ___________________ License # _______________
Phone (H)_____________________(C) _____________________ Occupation __________________________
Email____________________________________________ Lead Source_______________________________
q Go Paperless

Household Information
Current Carrier ______________________________________ Continuous Liability _____________________
Current Exp Date ________________ Prior Limits _________________ Residence Type ___________________

Multiline Discounts
q Home
q Rent
q Mobile Home
q Boat/Watercraft
q Off Road & Other q Motor Home
County/Municipality ___________________________________

q Life
q Tvl Tr

q Motorcycle

Drivers
HH
Marital
Relation Status

Driver

Good Student
q Yes
Senior Defensive Driver q Yes

Vehicles
Year

32-7978 1-11 Page 1 of 5

Make

DOB

q No
q No

Model

Gender

Occupation

SS#

License Number

Driver Name __________________________________

Driver Name __________________________________

VIN

Coverages Desired

Auto Client
Information Worksheet
Coverage Limits
Coverage

Current Limit

Bodily Injury
Property Damage
Uninsured/Underinsured Motorist
Medical Coverage/PIP
Comprehensive Deductible
Collision Deductible
Collision Plus/Loss of Use
Rental Reimbursement
Business Use
Custom Amount

Other Proposed Coverages

Glass Deductible Buyback
Flex Package
New Car Pledge

q Yes
q Yes

Proposed Limit

q K1 q K2 q K3 q K4 q K5

q No
q No

q Yes q No
q Yes q No
q Yes q No

Vehicle ___________________________________
Vehicle/Amount ____________________________

Towing & Road Service

Extended Theft to Stereo/Tapes/CD
Amount _____________________

Lienholder Information
Vehicle _____________________________________
Name of Company ___________________________
Address ____________________________________
City ____________________ State _____ ZIP _____
Loan # _____________________________________

q Yes q No
q Yes q No

Vehicle _____________________________________
Name of Company ___________________________
Address _____________________________________
City ____________________ State _____ ZIP _____
Loan # _____________________________________

Payment Plan
q Full/One Pay
q Monthly EFT
q Quarterly
q Monthly Credit/Debit Card
q Semi-Annual
q Monthly Paper Bill
q Add to Existing Billing Acct. ________________
Losses/Claims/Tickets
Enter details on any known claims, tickets or losses
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

32-7978 1-11 Page 2 of 5

Home/Renters Client
Information Worksheet
Premium Escrowed

Effective Date ___________________

q Yes

q No

Primary Named Insured Information (Home and Renters Quotes)

Name _____________________________________________________________________________________________

Address___________________________________ City _____________________ State_____ ZIP__________

SS# __________________________________________________ DOB _______________________________
Phone (H)_____________________(C) _____________________ Occupation __________________________
Email____________________________________________ Lead Source_______________________________
q Go Paperless

Household Information (Home and Renters Quotes)

Policy Type __________________________________ Prior Carrier: _________________________________

Multiline Discounts (Home and Renters Quotes)

q Life

q Smoker

q Auto

Dwelling (Home and Renters Quotes)

Year Built _____________ Square Feet _____________ Style __________________ Number of Units _______________
Foundation Type ____________________________ q Sprinklers
q Central Burglar
q Central Fire
q Outside City
q Home Security (Renters only)
q Local Smoke/Fire (Renters Only)
Roof Type ____________ q Out of Production
Roof Year _____________ Fuel Type _____________

Dwelling (Home Quotes Only)

Occupancy ____________________ Exterior Walls ________________________________________________
Foundation Shape __________________________ q Pool q Fenced q Deck q Basement q Renovated
Roof UL Rating ___________________________ Garage Type ___________________________
Number of bathrooms: ____ Standard ____ Custom ____ Luxury ____Economy ____ Bath

Losses/Claims (Home and Renters Quotes)

Enter details on any known claims or losses
______________________________________________________________________________________
______________________________________________________________________________________
Protection Class (Home and Renters Quotes)
Hydrant within 1000 Feet
q Yes
Uncleared Brush within 50 Feet
q Yes

q No
q No

Territory ___________________________
Designated Brush within 150 feet
q Yes

q No

Reconstruction Cost (Home Quotes Only)

Interior Walls ___________________ Interior % Finished ___________ Const Technique ________________
Cathedral Ceiling % _________ Kitchen Grade
q Standard q Custom q Economy q Luxury
Site Access ________________________ Evap coolers (#)__________
Fireplace Chimney (# Metal) ___________ Fireplace Chimney (# Masonry) __________
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Home/Renters Client
Information Worksheet
Reconstruction Cost (Home Quotes Only) Continued
Interior Wall Covering % _____________________________________________________________________
Floor Covering % ___________________________________________________________________________
Wall Height q 8 feet q 9 feet q 10 feet Framing q Post/Beam q Steel stud q 2x4 q 2x6
q Air Conditioning
q Balcony
q Elaborate Roof
Basement % __________ Basement % Finished __________ Walkout Basement q Yes q No
Additional Information (Home Quotes Only)
q Additional Furnace
q Attached Carport
q Composite Deck
q Central Stereo System
q Intercom System
q Jacuzzi
q Porch Screened
q Redwood Deck
q Wood Spiral Staircase q Porch Open

q
q
q
q
q

Breezeway Open
Greenhouse
Metal Spiral Staircase
Solar Room
Central Vacuum

q
q
q
q

Breezeway Screened
Hot Tub
Patio Cover
Wood Deck

_____ Bay Windows

_____ Sky Lights
_____ Wet Bar

_____ Exterior Shutters

_____ Greenhouse Windows
_____ Stained Glass Windows

Enter Quantity Below

_____ Atrium Doors

_____ French Doors
_____ Sliding Glass Doors

_____ Atrium Windows

_____ Picture Windows
_____ Solar Panels

Additional Allowance $_______________

Coverage/Premium Information (Home Quotes Only)

Next Gen Package
q None
q Basic Package w/Contents
Modified
q Yes q No
Roof ACV
q Yes
Contents Rpl q Yes q No
Earthquake Masonry q Yes

q Basic Package w/o Contents

q No
q No

Coverage Limits (Home and Renters Quotes)

Coverage
Dwelling (Home Quotes Only)
Personal Property
Separate Structures (Home Quotes Only)
Loss of Use
Personal Liability
Guest Medical
Property Deductible

32-7978 1-11 Page 4 of 5

Current Limit

Proposed Limit

Home/Renters Client
Information Worksheet
Optional/Detail Coverages (Home and Renters Quotes)
q Identity Shield
q Extended Repl q Eco-Rebuild
q Residence Glass
q Child Care
q Personal Injury
q Additional Premises q Watercraft
q Farm Liability
q Leased Farm Land q Sewer & Drain $_________________

q Loss Assessment
q Bldg Ordinance
q Farm Off Prem
q EQ Basic $_________ Ded $_________
Enter details on any increased limits or schedule requirements for jewelry, computers, furs, silverware, guns, cameras, etc.
__________________________________________________________________________________________
State Specific Coverages
__________________________________________________________________________________________

Additional Household Information (Home and Renters Quotes)

Additional Named Insured ____________________________________________________________________
SS# _____________________________________________ DOB ____________________________________
Add Name to Bill q Yes q No
Add Name to Declarations q Yes q No
Additional Policy Information (Home and Renters Quotes)
Inspected
q Yes q No
Plumbing Type ____________________ Primary Heat ________________
Circuit Bkr q Yes q No
Amps __________________
Business on property q Yes q No
Extended address for EOI/MOI q Yes q No
Any Unusual Hazards q Yes q No
Dogs on Property q Yes q No (Breed)________________________________________________________
Different Mailing Address/Legal Description q Yes q No _______________________________________
Additional Policy Information (Home Quotes Only)
Purchase Date_______________ Laundry Room Loc _______________ # of Roomers/Boarders _____________
Mortgagee Information (Home Quotes Only)
Name of Company ___________________________
Address ____________________________________
City ____________________ State _____ ZIP _____
Loan # _____________________________________
Payment Plan (Home and Renters Quotes)
q Full/One Pay
q Quarterly
q Semi-Annual
q Add to Existing Billing Acct. ________________

32-7978 1-11 Page 5 of 5

q Monthly EFT
q Monthly Credit Card
q Monthly Paper Bill