Personal Insurance Information Form – J. Healan Baker Agency

Basic Information

First Name *Primary Named Insured

Last Name *Primary Named Insured

First NameSecond Named Insured

Last NameSecond Named Insured

Address Line 1 *

Address Line 2

City *

State/Province *

ZIP Code *

Is this where you live, park your car, and get your mail? *YesNoIs this you physical and mailing address? Is this where you park your car at night?

Mailing Address

Mailing Address Line 2

City

State/Province

ZIP / Postal Code

Phone *

Email Address *

How did you hear about the J. Healan Baker Agency?

Which policies do you currently have or are interested in getting quotes for? Please select all that apply *AutoHomeownersRentersUmbrellaRecreational Vehicle - Boat - ATV

Auto

How many vehicles are in your household?

How many licensed drivers live in your household?

Are all of your vehicles registered to you or you & your spouse in your state of residence?YesNo

If no, please explain

Do any drivers in your household maintain their own insurance?YesNo

If yes, please note vehicle and driverFor example, an adult child with their own insurance in household or parent with own insurance at same residence.

Are any of your vehicles used for delivery, rideshare, or taxi?YesNoLyft, Uber, Grubhub, etc..

Please provide names, date of birth and drivers license numbers for all licensed drivers in your household.This will allow us to access reports and present you with accurate quote information.

Please provide VIN for all your vehicles. (You may also provide the year, make, model, if unavailable)

Who is your current auto insurance carrier? *

How long have you had coverage with your current company?

Current Liability Limits

Do you need physical damage (collision) coverage for your autos?YesNo

Preferred deductible for physical damage coverages

Do you need roadside assistance or rental car coverage?YesNo

Do You need Loan/Lease Gap Coverage?YesNo

Have you maintained continuous insurance, without a lapse in coverage, for the last 12 months?YesNo

Has anyone in the household had any tickets, violations, or accidents in the last 5 years? (regardless of fault)YesNo

If yes, please give details of each incident. Include dates, damages, violations, any injuries (and who was injured) please give as much info as possible.

Any Driver's License suspensions or SR-22 financial responsibility filings in 5 years?YesNo

If yes, please explain

Please provide any additional details requested by your agent here.

Current Policy Declarations Page

Please upload the declarations page for your auto policy and any other policy you are seeking replacement coverage for.

Homeowners

Do you own your home?YesNo

Is your home a single family, frame built home? (Not a mobile or log home)YesNo

Is this a new home purchase?YesNo

What is your anticipated Closing Date?

Please provide contact information for your Loan Officer.Name, phone, email or fax

Approximately, what is your loan amount?

Is your home purchase a Foreclosure or Short Sale?YesNo

Is your home located in a Flood Zone?YesNo

Has your Homeowners or Renters insurance been cancelled, declined or non-renewed in the last 3 years?YesNo

Do you own any animals that have ever bitten or shown aggressive tendencies towards other animals or people?YesNo

Do you or will you rent this home? If so, on what basis?Long term lease, Airbnb or vacation rentals?

How many days out of the year will you rent this property?Daily, weekly, monthly, semi annual or annual agreements?

Number of Months the home will be unoccupiedunoccupied = no one living in the home

Name & Address of Mortgage CompanyIf you have a mortgage, please provide the mortgagee clause as shown on your current policy.

Year BuiltYear the home was originally built

Year RenovatedFor homes older than 20 years, what year was your roof and central heat last renovated or replaced?

Main Home Square FootageExclude any basements, decks, porches or patios

Will this be your Primary Dwelling?Will this be your year-round, primary home? (Not a secondary, seasonal or temporary home)

Please select all that apply to the homeDeadbolt Locks on Exterior DoorsSmoke detector on each levelFire Extingisher in the homeBurglar or Fire Alarm (smart, local, central)Water monitoring system (pipes, septic)

Distance to Fire Hydrant1000ft is roughly 3 football fields

Any Property Claims in the last 5 years?YesNoRegardless of address - Please provide details in additional information.

Claim DetailsDate of Loss - Cause of Loss - Claim Amount ($) - Damages Repaired?

Requested Limit for Personal LiabilityPersonal Liability - protects insured from lawsuit

Medical Payments to OthersGuest medical - pays medical expense if a guest is injured on your property.

Deductible OptionAmount of a loss assumed by the insured before a policy would pay damages/claim.

Additional Information

Tenant

What type of home are you renting?

Do you currently have renter's insurance?YesNo

Distance to Fire Hydrant1000ft is roughly 3 football fields

Do you own any animals that have ever bitten or shown aggressive tendencies towards other animals or people?YesNo

How much coverage do you need for your personal belongings?$25,000-$500,000

Requested Limit for Personal LiabilityPersonal Liability - protects insured from lawsuit

Deductible OptionAmount of a loss assumed by the insured before a policy would pay damages/claim.

Medical Payments to OthersPays medical expenses if a guest is injured on your property.

Additional Information

Any Property Claims in the last 5 years?YesNoRegardless of address - Please provide details in additional information.

Claim DetailsDate of Loss - Cause of Loss - Claim Amount ($) - Damages Repaired?

Do you need to list an Additional Interest?YesNo

Name and Address of Additional InterestProvide the person or business to be listed as additional interest and why we are listing them (landlord/apartment mgr)

Umbrella

LimitWhat is the current or requested limit of liability?

Do you currently have this coverage with another company?YesNo

Are you also requesting coverage for your personal auto and homeowners insurance on this quote request?YesNo

Do you own any property/vehicles not currently insured with us? Please list these items.

Recreational Vehicle - Boat - ATV

Please provide make, model, and VIN for vehicle and trailer (when applicable)

Are these items currently insured?YesNo

Is there a lien holder?YesNo

Name and Mailing address of Lien Holder

Garaging Address

Additional Info Needed to Quote

Documents Requested by Agent

Drivers License, registration, photos, and documents requested by agent to quote.

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