Personal Lines Intake Form – IABU – Reed Insurance Who do we return the quote to?(Required) Pattie Jones Melissa Calhoun 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 Phone(Required)Email(Required) 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 Number Drivers License StateLAMSTXARSpouse 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 Number Number of household members including childrenDo you have a Driver? Yes No Drivers InformationDriver'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 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.
