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Personal Lines Intake Form - IABU - Integra Insurance

Who do we return the quote to?(Required)
Prospect Name(Required)
Policy Effective Date(Required)
Prospect Date of Birth(Required)
Address (physical)(Required)
Primary applicant employment:(Required)
Spouse Name (if applicable)
MM slash DD slash YYYY
Spouse employment:
Select Lines of Business(Required)
Does the prospect own, rent, or have a condo they live in?(Required)

Home

Enter year of last update to the following:(Required)
Roof
Electric
Plumbing
HVAC
 
Is this a new purchase?
MM slash DD slash YYYY
Prior Home Address

Auto

Note: 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.
Auto Liability Limit Requested(Required)
Uninsured Motorist Limit Requested(Required)
Uninsured Motorist Property Damage Requested(Required)
PIP(Required)
Med Pay Limits(Required)
Comp Deductible(Required)
Collission Deductible(Required)

Umbrella

Umbrella Limits requested(Required)
Please state the number of each owned:
Home
Autos
Boats / Jet Skis
Motorcycles
ATVs
RV/Camper
 

Example: Any underwriting notes: Trampolines, pools, dogs, etc
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 20 MB, Max. files: 4.
    Dec pages, driver's licenses, etc.

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