Reed Insurance Personal Lines Intake Form Who do we return the quote to?(Required) Charles Yajima Mizpah Yanson Prospect Name(Required) First Last Policy Effective Date(Required) Month Day Year Prospect Date of Birth(Required) Month Day Year Social Security Number:Address (physical)(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone(Required)Email(Required) Can we text you? Yes No Prior Auto Insurance Company:Prior Home Insurance Company:Primary applicant employment:(Required) Executive or similar management position Educator (teacher or administrator) Active Military Professional (specific degree) Manual Laborer Retired Other Drivers License NumberDrivers License StateLAMSTXARSpouse or Domestic Partner Spouse Domestic Partner Neither Their Name (if applicable) First Last Spouse date of birth (if applicable) MM slash DD slash YYYY Spouse employment: Executive or similar management position Educator (teacher or administrator) Active Military Professional (specific degree) Manual Laborer Retired Other Spouse Drivers License StateLAMSTXARSpouse Drivers License NumberNumber of household members including childrenAny other drivers in your household? Yes No Drivers Information # 3Driver's Name:(Required) First Last Driver's License:(Required)Driver's Date of Birth:(Required) MM slash DD slash YYYY Any other drivers in your household? Yes No Drivers Information # 4Driver's Name:(Required) First Last Driver's License:(Required)Driver's Date of Birth:(Required) MM slash DD slash YYYY Select Lines of Business(Required) Homeowners Personal Auto Umbrella Does the prospect own, rent, or have a condo they live in?(Required) Own their home Rent where they live Own a condo Condo Limit (building portion they are required to insure)(Required)Personal Property Limit (Condo or Rental)(Required)Number of Room (Condo or Rental)(Required)Square feet of living area (Condo or Rental)(Required)Number of floors (Condo or Rental)(Required)HomeEnter year of last update to the following:(Required)RoofElectricPlumbingHVAC Add RemoveDo you have a living area? Yes No Square feet of the living area:(Required)Is this a new purchase?(Required) Yes No Purchase Date:(Required) MM slash DD slash YYYY Expected Closing Date(Required) MM slash DD slash YYYY Prior Home Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code AutoNote: Please select the coverage limits below.. Comprehensive deductible will be $500. Collision deductible will be $1.000. Any other coverage options will not be included other than as selected below. Number of autosAuto Liability Limit Requested(Required) $50,000 / $100,000 / $50,000 $100,000 / $300,000 / $100.000 $250,000 / $500,000 / $150,000 Uninsured Motorist Limit Requested(Required) $50,000 / $100,000 $100,000 / $300,000 $250,000 / $500,000 Rejected Uninsured Motorist Property Damage Requested(Required) $25,000 $50,000 $100,000 Rejected Med Pay Limits(Required) $5,000 $10,000 $25,000 Rejected Deductible:(Required) $250 $500 $1,000 $1,500 $2,000 Rejected Other UmbrellaUmbrella Limits requested(Required) $500,000 $1,000,000 $1,500,000 $2,000,000 Please state the number of each owned:HomeAutosBoats / Jet SkisMotorcyclesATVsRV/Camper Add RemoveUnderwriting QuestionsPoolIf pool, is it fencedif pool, diving boardif pool, slideWood fireplaceTrampolineif Trampoline, is it fencedTell me about any home claims that you have had in the last 5 yearsTell me about any driving violations from the last 5 yearsTell me about any auto claims that you have had in the last 5 yearsUpload supporting documents Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 20 MB, Max. files: 4. Dec pages, driver’s licenses, etc. Untitled First Choice Second Choice Third Choice
