Personal Lines IntakeStep 1 of 147%Primary Insured InformationName(Required) First Last Phone(Required)Email(Required) Drivers LicenseDate of Birth(Required) MM slash DD slash YYYY OccupationMarital Status Single Married Divorced WidowedEducation High School Associate Degree Bachelor's Degree Graduate or Professional Degree Some CollegeSpouse InformationSpouse Name First Last Spouse PhoneSpouse Email Spouse Birth Date MM slash DD slash YYYY Spouse Drivers LicenseSpouse Education High School Associate Degree Bachelor's Degree Graduate or Professional Degree Some CollegeSpouse OccupationHow did you hear about Clear View? Client Referral Mortgage Referral Realtor Referral Financial Advisor Referral Other Referral Facebook Google Instagram OtherReferred By Name First Last Preferred AdvisorAmanda ChenApril HolmesGerald ShopeTyson ClarkWhat type of insurance can we quote for you? Auto Home Condo Umbrella Investment Property Motorcycle/Slingshot/ATV Golf Cart Boat RV OtherWhat other type of insurance can we quote for you?New purchase or already own the property? New Purchase Already OwnHow do you use the property? Primary Residence Secondary Residence RentalCurrent Address (No PO Boxes)(Required) Street Address Address Line 2 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 Address of Property Being Purchased Same as current address Street Address Address Line 2 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 Would you like to add a different mailing address? Yes NoMailing Address Street Address Address Line 2 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 Property InformationNumber of Adults Living in Home12345+Number of Children Living in Home012345+Year BuiltPurchase/Closing Date MM slash DD slash YYYY Sq FtBedrooms 1 2 3 4 5# of stories 1 1.5 2Bathrooms11.522.533.544.5Garage None 1 Car 2 Car 3 Car 4 CarAdditional Structures Yes NoAdditional Structure DescriptionMore than 5 acres? Yes NoFireplace Yes NoSwimming Pool(Required) Yes NoSwimming Pool Enclosed/Fenced?(Required) Yes NoDiving Board or Slide?(Required) Yes NoTrampoline(Required) Yes NoTrampoline Has Net?(Required) Yes NoGated Community? Yes, Passkey Gate Entrance Yes, 24 Hour Manned Gate NoneMonitored Burglar/Fire Alarm? Yes NoSolar Panels Yes NoHow Many Solar Panels? Add RemoveDog(s)?(Required) Yes NoDog Breeds Add RemoveIf mixed please indicate type of mix.Any bite history or security training?(Required) Yes NoAre you aware of any previous settlement or sinkhole issues on the property?(Required) Yes NoHave you had any home or renter's insurance claims in the past 5 years?(Required) Yes NoHome Information ContinuedExterior MaterialBrick VeneerClapboardVinyl SidingStone VeneerStuccoRoof MaterialComposite ShinglesAsphalt ShinglesArchitectural ShinglesMetalTileYear Roof UpdatedYear Electrical UpdatedYear Plumbing Updated?Year HVAC UpdatedDwellingLoss of UseWind/Hail DeductibleAll Other Perils DeductibleOther StructuresPersonal PropertyLiability $100,000 $300,000 $500,000Medical Payments $5,000 Second Choice Third ChoiceLoan AmountScheduled Personal Property Artwork Collectibles Firearms Jewelry Technology OtherValuable Items List (Click the + to add additional items)Item DescriptionReplacement ValuePurchase Date Add RemovePlease list each item and include an appraised/estimated value. Only one item per row please.Home NotesAuto InformationTotal Drivers in Home(Required) 1 2 3 4 5Total Vehicles in Home(Required) 1 2 3 4 5Liability Limits $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 $300,000 CSL $500,000 CSLUM/UIM $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 $300,000 CSL $500,000 CSLComprehensive Deductible Decline Comp $100 $250 $500 $1,000Collision Deductible Decline Collision $100 $250 $500 $1,000Rental Reimbursement Yes NoPIP Decline Both PIP MedicalPIP/Medical $2,500 $5,000 $10,000VehiclesYearMakeModelVIN Add RemoveClick the + to add more vehicles.How is vehicle #1 used?(Required) Commute Pleasure Business Rideshare DeliveryHow is vehicle #2 used?(Required) Commute Pleasure Business Rideshare DeliveryHow is vehicle #3 used?(Required) Commute Pleasure Business Rideshare DeliveryHow is vehicle #4 used?(Required) Commute Pleasure Business Rideshare DeliveryHow is vehicle #5 used?(Required) Commute Pleasure Business Rideshare DeliveryPlease skip to the next page. We already collected your spouse's information earlier in this form.Driver #2Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers LicenseOccupationRelationship to you Spouse Child Parent OtherDriver #3Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers LicenseOccupationRelationship to you Spouse Child Parent OtherDriver #4Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers LicenseOccupationRelationship to you Spouse Child Parent OtherDriver #5Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Drivers LicenseOccupationRelationship to you Spouse Child Parent OtherInvestment PropertyAddress Street Address Address Line 2 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 Property Status Currently Occupied with Tenants Listed For Sale - No Occupants Listed For Rent - No Occupants Undergoing Renovations - VacantMotorcycle/Slingshot/ATVName of Primary Driver First Last Vehicle Type Motorcycle Slingshot ATVIs Vehicle Used for Racing? Yes NoCurrent Motorcycle License Yes NoHas Driver Completed Safety Course? Yes NoYearMakeModelVINUmbrellaIn order to purchase an umbrella liability policy you must have auto liability limits of at least $250,000/$500,000/$250,000 and home/renters liability of at least $300,000.(Required) I understand that if the current liability limits on my auto and home/renters policies do not meet those minimums I will not be eligible to purchase an umbrella liability policy.How many homes do you own?This includes primary, secondary, vacation, rental and investment properties.How many home/renters claims have you made in the last 5 years?How many vehicles do you own?How many auto claims have you made in the last 5 years?Any drivers on your auto policy have an at-fault accident in the last 5 years? Yes NoDo you own any of the following items? Boat/Yacht Motorcycle ATV Golf Cart Vacant Land BusinessBoat InformationWhere is boat stored? Primary Residence Marina - Slip Marina - Dry Stack OtherYearMakeModelHull NumberMotor Type Inboard OutboardTop Speed (MPH)Boat LengthBoat is used for racing? Yes NoDo you own a boat trailer? Yes NoGolf CartYearMakeModelPrimary Use Transportation GolfingFuel Type Electric GasRecreational VehicleRV Type 5th Wheel Motorcoach OtherYearMakeModelPlease upload current policy documents if you have them available.Max. file size: 1 GB.Consent(Required) Clear View Insurance Specialists may contact me via phone call, email and text message.Notes - Comments - DetailsCAPTCHA
