Personal Lines Intake Form – IABU – Integra Insurance Who do we return the quote to?(Required) Jaime Kirkland Ana Salazar Kristyn Wilkie Prospect Name(Required) First Last Policy Effective Date(Required) Month Day Year Prospect Date of Birth(Required) Month Day Year 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 Phone(Required)Email Primary applicant employment:(Required) Executive or similar management position Educator (teacher or administrator) Active Military Professional (specific degree) Manual Laborer Retired Drivers License Number Drivers License StateTXLAMSARSpouse 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 Spouse Drivers License Number Spouse Drivers License StateTXLAMSARNumber of household members including childrenSelect Lines of Business(Required) Homeowners / Renters / Condo 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 RemoveIs this a new purchase? Yes No 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 PIP(Required) $2,500 $5,000 $10,000 Rejected Med Pay Limits(Required) $5,000 $10,000 $25,000 Rejected Comp Deductible(Required) $500 $1.000 $2,500 Rejected Collission Deductible(Required) $500 $1.000 $2,500 Rejected 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 RemoveAny additional notesExample: Any underwriting notes: Trampolines, pools, dogs, etcUpload 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.
