Personal Lines Data Sheet

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					personal lines
data sheet
                                                                                                                                                                                 Rev. 3/18/2011

                       Form Required:                        Condo/Co-Op:                  Occupancy Type:                             Purchase:                         CSR:

                       Named Insured(s):                                                                                                      Effective Date:
                       Insured Location:
                                                                                                                                              lpr data
                       Date of Birth:                                                                                                         Current Carrier:
personal information

                       SSN:                                                                                                                   Expiring Premium:
                       Home #:                                                                                                                Current Policy #:
                       Work #:                                                                                                                Current Term:
                       Other #:
                       E-Mail:                                                                                                                additional quotes requested:
                       Occupation:                                                                                                                           Flood
                       Employer Name:                                                                                                                         Auto
                       Employer Address:                                                                                                                  Umbrella
                                                                                                                              YES    NO       Notes: (K&R, WC, Serve on Board, etc)
                       Dwelling/A&A:                                                            Off-Premise Theft:
requested coverage

                       Other Structures:                                                        Water Backup:
                       Personal Property:                                                       RC Dwelling:
                       Liability:                                                               RC Contents:                                  Schedule/Blanket (Specify):
                       Deductible:                                                              Special Contents:
                                                                                                ID Fraud:
                                                                                                Personal Injury:

                                                                                                                              YES    NO
                       Distance to Water:                           Heat Type:                              Trampoline:
property information

                       Construction Type:                           Oil Tank Loc:                           Pool:
                       Year Built:                                  Basement:                               Slide:                            updates (Partial or Complete)           P C
                       Square Feet:                                 % Finished:                             Diving Board:                     Heat:
                       Roof Material:                                                                       Pool Fence:                       Electric:
                       # of Stories:                                Circuit Breakers:                       Property Fence:                   Plumbing:
                       # of Units:                                  Wood Burning Stove:                                                       Roof:
                                                                    Prior Losses:                                                             Pets:

                       Smoke Detector:                                                          Perimeter Security:                    Specify:
                       Dead Bolt:                                                               Gated Community:
safety features

                       Fire Extinguisher:                                                       Sprinklers:                         In All Living Areas:
                       Burglar Alarm:             With Central Station:                         Doorman:
                       Fire Alarm:                With Central Station:                         Caretaker:                             Retiree/Prime-Time Credit:
                       Gas/Water Detection or Low Temp Monitor:

                                                                                                                                                           Effective Date:
payment & notes

                                                                                                                                                           Sent Thank You:
                                                                          mortgagee info

                       Insured Bill @ Inception:                                                                                                           Alarm Certificates:
                       Mortgagee Bill @ Inception:                                                                                                         Follow Up Set for:
                       Insured First Year, then Mortgagee:                                                                                                 LPR Sent:

                       Producer/Sub-Broker:                          /                             Date Submitted:                            Source:
personal lines
data sheet
                                                                                                                                                                                  Rev. 3/18/2011

                                                         driver 1                             driver 2                        driver 3                              driver 4
                       Named Insured(s):
                       Garage Address:

                       Date of Birth:
personal information

                       DL # / State:
                       Home #:
                       Work #:
                       Other #:
                       Employer Name:
                       Employer Address:

                                    year        make                           model                                          vin #                                             usage
vehicle information

                                                                    all vehicles
                                                                                               vehicle # 1      vehicle # 2           vehicle # 3          vehicle # 4         vehicle # 5
                                                          current                  proposed
                       Property Damage:
                       Supplemental UI:
                       Basic PIP:
coverage information

                       Additional PIP:
                       Medical Payments:
                       COMP Deductible:
                       Full Glass:
                       COLLISION Deductible
                       Towing Assistance:
                       Rental Coverage:
                       Roadside Assistance:

                       Current Carrier:                                                          credits
lpr data

                       Expiring Premium:                                                         Alarm:                  Defensive Driver                    Homeowner:
                       Current Policy #:                                                         ABS:                    Completion:                         Renter:
                       Current Term:                                                             Air Bags:                                                   Live with Parents:

                       Tickets or Accidents in past 5 years:                                                                                                          checklist
                                                                                                                                                          Effective Date:
history & comments

                       Comments:                                                                                                                          Sent Thank You:
                                                                                                                                                          Follow Up Set for:
                                                                                                                                                          LPR Sent:

                       Producer/Sub-Broker:                                /                        Date Submitted:                             Source: