PL Intake Form Which lines are you looking for? Auto Home Valuable Articles Boat Camper/RV ATV/UTV Secondary Home Umbrella Life Other Other Lines of businessProducer NameClinton MuddCailee MuddDalila PalmaHow did you hear about us?SelectReferralOnline SearchSocial MediaDave RamseyOtherWho Should be Assigned?Clinton@muddinsurance.comcailee@muddinsurance.comcsr@muddinsurance.comEffective Date MM slash DD slash YYYY Primary Insured Name First Last Primary Insured PhoneCan we text this number? Yes No Primary E-mail Primary insured Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Insured Date of Birth MM slash DD slash YYYY Marital Status: Married Single Divorced Widowed Other Primary Insured Occupation and Highest Level of EducationSecondary Insured Name First Last Spouse/secondary Date of Birth MM slash DD slash YYYY Secondary Insured PhoneCustomer gave permission to text this number? Yes No Secondary Insured Occupation and Highest Level of EducationAre you currently insured? Yes No Current Carrier NameHow long have you been with this carrier?current premium:Auto questionsNumber of Vehicles12345Vehicle InfoYear/Make/ModelVinDeductible Add RemovePreferred Liability LimitsLiability Limits / 250/500Property Damage LimitRoad SideGlassMedicalUM Add RemovePreferred Liability LimitsUIMComp DedColl DedLean/Lease/Loan infoRental/Transport Expense Add RemoveNumber of drivers12345Drivers Info (for all household members over 15 years of age)NameDOBDrivers LicenseState of issueAny Violations/Tickets in last 3 years?(Speeding, etc)SR-22 Add RemoveAre there any other members of the household of driving age not listed?YESNOIf yes, who is not listed? Are they insured elsewhere?On any auto policies, including glass and towing, how many auto claims in last 5 years? (If any, explain type of claim)Home QuestionsHome DetailsYear BuiltType of home (ranch, 1 story, 1.5 story, 2 story, etc)Squarefootage (above ground)type exterior wall (vinyl siding, aluminum siding, brick, wood siding, log, etc) Add RemoveHome DetailsType of floors in the home (list with percentage)Number of bathroomsFireplacesType of roof covering Add RemoveHome DetailsFoundation Type (basement, crawl space, slab, etc)If basement, Sump Pump?If basement, percentage finished?Mortgage? Add RemoveHome DetailsIs premium escrowedName of Mortgage companyAny Alarms or Water Sensors? (Fire, Burglar, Cameras, etc)If Yes, sent to phone, monitor service, directly to emergency department? Add RemoveHome DetailsGarage - Attached, Detached, NoneHow many cars? Add RemoveAny pets? Yes No If yes, what type (if a dog, any bite history)?Pool? Yes No If YesInground or Above GroundMax Depthslide or diving boardFence with self locking gate Add RemoveCoverage Options - if coverage line not desired enter "no"Current Coverage A (coverage on home)Liability LimitWater Sewer BackupFlood Add RemoveCoverage Options - if coverage line not desired enter "no"Mine SubsidenceValuable ArticlesSink HoleEarthquake Add RemoveUpdates to propertyRoof- year replacedPlumbing - Year & Full or PartialElectrical - Year & Full or PartialHVAC Year & Full or Partial Add RemoveFor any property you've owned, how many home claims in last 5 years? (If any, explain type of claim)Boat QuestionsBoat InfoYear/Make/ModelHull ID/VinInboard/OutboardTotal HorsepowerTop Speed$ Value Add RemoveTrailer InfoYear/Make/ModelHull ID/VinInboard/OutboardTotal HorsepowerTop Speed$ Value Add RemoveBoat Coverage/Info NeededLiability Limits / 250/500Property Damage LimitYears of Boat ExperienceUninsured/Underinsured limit Add RemoveBoat Coverage/Info NeededComp DedColl DedLean/Lease/Loan infoAmount Paid For Any Boat Claims in last 5 years Add RemoveCamper/RV QuestionsCamper/RV InfoYear/Make/ModelVinTotal length# of Slides$ Value Add RemoveCamper/RV Info NeededYears of Camping ExperienceDays a Year UsedComp Ded Add RemoveCamper/RV Info NeededColl DedLean/Lease/Loan infoAmount Paid For Any Camper/RV Claims in last 5 years Add RemoveUmbrella QuestionsUmbrella LiabilityLiability Limits 1mil, 2 mil, etc.Include Uninsured Motorist Bodily Injury (Y/N)Do you own other properties? (second home, rental, darm, hunting, etc) Add RemoveUmbrella LiabilityDo you own any ATV's or UTV's not previously listed?Do you own any other recreational vehicles?Do you or second named insured serve on a non-profit board? Add RemoveAttachments & NotesFiles Drop files here or Select files Max. file size: 5 MB. Notes on the account (include info on ATV/UTV, Secondary Property and Other
