1StakWise - PL Intake

Step 1 of 26 - Personal Lines Intake

Assigned Advisor

How did you hear about us?

Internal Referral Sources

Who Referred You?

What type of insurance can we quote for you?

Auto

Home

Condo

Mobile Home

Umbrella

Rental Property

Motorcycle/Slingshot/ATV

Golf Cart

Boat

Other

What other type of insurance can we quote for you?

Primary Contact Information

Name

First Last

Phone

Date of Birth

Month

Day

Year

SSN

Occupation

Marital Status

Single

Married

Divorced

Widowed

Spouse Information

Spouse will be considered driver #2 if quoting auto.

Name

First Last

Phone

Occupation

Date of Birth

Month

Day

Year

SSN

Current address or location of home to be insured

Street Address Address Line 2 City State ZIP Code

County

Years At Current Address

Mailing address different than location address?

Mailing Address

Street Address Address Line 2 City State ZIP Code

Prior Address

Street Address Address Line 2 City State ZIP Code

Condo/Home Information

Property Type

New purchase or already own the condo/home?

New Purchase

Already Own

How do you use the condo?

Primary Residence

Secondary Residence

Rental

Purchase Date/Closing Date

Month

Day

Year

Purchase Price

Year Home Was Built

Acres

Sq Ft

# of stories

1.5

Construction Type

Roof Material

Roof Shape

Year Roof Updated

Any updates to heating, electrical or plumbing?

Heating

Electrical

Plumbing

Year Heating Updated

Type of Update

Year Electrical Updated

Type of Update

Year Plumbing Updated?

Type of Update

Foundation

Finished Basement %

Garage

Yes Attached

Yes Detached

Car Port

None

Garage

1 Car

2 Car

3 Car

4 Car

Detached Structures

Yes

Detatched Structure

Year Built

Detached Structure Sq. Footage

What Type of Structure?

What Other Type?

Detatched Building Exterior

Other Exterior Material

Detatched Structure Roof Type

Other Roof Type

Detatched Building Roof Age

Detached Structures Used For Farming Purposes?

Yes

Which building and how is it used?

Fireplace

Yes - Gas

Yes - Wood

Woodstove

Yes

More than 5 Acres

Deck/Patio

Yes - Covered

Yes - Screened

Yes - Enclosed

Deck/Patio Size

Bathrooms

Deck Material

Flooring

Wood %

Carpet %

Ceramic %

Vinyl %

Wood Laminate %

OTHER (FILL IN)

Swimming Pool

Yes

Swimming Pool Fenced and Locked?

Yes

Diving Board or Slide?

Yes

Trampoline

Yes

Trampoline Has A Net?

Yes

Monitored Burglar/Fire Alarm?

Local

Monitored

None

Monitored Alarm Company Name

Responding Fire Department?

Miles to Fire Department?

Paid Fire Subscription Required?

Yes

Unknown

Fire Protection Class

Any Pets?

Dog Breeds

If mixed please indicate type of mix.

Any bite history or security training?

Yes

Farming Operations?

Yes

Any Horses?

Yes

How Many?

Any Cattle?

Yes

How Many?

Any Other Livestock?

Yes

Types of Livestock

Livestock

How Many

Mobile Home

Width

Length

Tied Down

Yes

In Approved Mobile Home Park?

Yes

Name of Park?

On Private Land?

Yes

Manufacturer

Model

Serial #

Any attached additions?

If so, what?

Done by professional?

Yes

Condition of Mobile

Excellent

Good

Poor

If insured pays, how do they prefer to pay:

Full Pay

Two Pay

Four Pay

Monthly

Could you send a front/back photo of your home if we write your insurance?

Yes

New purchase or already own the condo/home?

New Purchase

Already Own

How do you use the condo?

Primary Residence

Secondary Residence

Rental

Purchase Date/Closing Date

Month

Day

Year

Purchase Price

Year Home Was Built

Acres

Sq Ft

# of stories

1.5

Construction Type

Frame Detail

Roof Material

Roof Shape

Year Roof Updated

Any updates to heating, electrical or plumbing?

Heating

Electrical

Plumbing

Year Heating Updated

Type of Update

Year Electrical Updated

Type of Update

Year Plumbing Updated?

Type of Update

Foundation

Finished Basement %

Garage

Yes Attached

Yes Detached

Car Port

None

Garage

1 Car

2 Car

3 Car

4 Car

Detached Structures

Yes

Detatched Structure

Year Built

Detached Structure Sq. Footage

What Type of Structure?

What Other Type?

Detatched Building Exterior

Other Exterior Material

Detatched Structure Roof Type

Other Roof Type

Detatched Building Roof Age

Detached Structures Used For Farming Purposes?

Yes

Which building and how is it used?

More than 5 acres?

Yes

Fireplace

Yes - Gas

Yes - Wood

Woodstove

Yes

Deck/Patio

Yes - Covered

Yes - Screened

Yes - Enclosed

Deck/Patio Size

Bathrooms

Flooring

Wood %

Carpet %

Ceramic %

Vinyl %

Wood Laminate %

OTHER (FILL IN)

Swimming Pool

Yes

Swimming Pool Fenced and Locked?

Yes

Diving Board or Slide?

Yes

Trampoline

Yes

Trampoline Has A Net?

Yes

Monitored Burglar/Fire Alarm?

Local

Monitored

None

Monitored Alarm Company Name

Responding Fire Department?

Miles to Fire Department?

Paid Fire Subscription Required?

Yes

Unknown

Fire Protection Class

Any Pets?

Dog Breeds

If mixed please indicate type of mix.

Any bite history or security training?

Yes

Farming Operations?

Yes

Any Horses?

Yes

How Many?

Any Cattle?

Yes

How Many?

Any Other Livestock?

Yes

Types of Livestock

Livestock

How Many

Scheduled Personal Property

Jewelry

Furs

Firearms

Art

Cameras

Musical Instruments

Other

Total Value of Jewelry Owned?

Total Value of Firearms Owned?

Total Value of Art/Cameras/Furs/Musical Instruments Owned?

Valuable Items List (Click the + to add additional items)

Please list each item and include an appraised/estimated value. Only one item per row please.

Home Notes

Farming

Farming Type

Annual Farming Income

Current Carrier Information

Current Carrier

Policy Expiration

MM slash DD slash YYYY

Dwelling Limit

Personal Property Limit

Liability Limit

Deductible

Current Premium

Escrowed

Yes

Mortgage Company

Have there been any home claims in the last 5 years?

Yes

Claims

Include Date of claim, Type of claim (wind/hail/water/lightning/other), Amount paid.

Auto Information

Total Drivers in Home

Total Vehicles in Home

Vehicle #1

Vehicle Year

Make

Model

VIN

Comprehensive Deductible

$250

$500

$750

$1,000

$1,500

Decline Comp

Collision Deductible

$250

$500

$750

$1,000

$1,500

Decline Collision

Business Use

Yes

Rideshare or Delivery?

Yes

Roadside

Yes

Decline

Rental Reimbursement

Decline

$50/Day

$75/Day

$100/Day

Vehicle #2

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Comprehensive Deductible

$250

$500

$750

$1,000

$1,500

Decline Collision

Collision Deductible

$250

$500

$750

$1,000

$1,500

Decline Comp

Business Use

Yes

Rideshare or Delivery

Yes

Roadside

Yes

Decline

Rental Reimbursement

Decline

$50/Day

$75/Day

$100/Day

Vehicle #3

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

Rideshare or Delivery

Yes

Roadside

Yes

Decline

Rental Reimbursement

Decline

$50/Day

$75/Day

$100/Day

Comprehensive Deductible

$250

$500

$750

$1,000

$1,500

Decline Comprehensive

Collision Deductible

$250

$500

$750

$1,000

$1,500

Decline Collision

Vehicle #4

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

Rideshare or Delivery

Yes

Roadside

Yes

Decline

Rental Reimbursement

Decline

$50/Day

$75/Day

$100/Day

Comprehensive Deductible

$250

$500

$750

$1,000

$1,500

Decline Comp

Collision Deductible

$250

$500

$750

$1,000

$1,500

Decline Collision

Vehicle #5

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

Rideshare or Delivery

Yes

Roadside

Yes

Rental Reimbursement

$50/Day

$75/Day

$100/Day

Comprehensive Deductible

$250

$500

$750

$1,000

$1,500

Decline Comp

Collison Deductible

$250

$500

$750

$1,000

$1,500

Decline Collision

Driver #1 (Named Insured)

Drivers License

Any tickets or accidents in the last 5 years?

Date

Description

Driver #2

Name

First Last

Phone

Date of Birth

MM slash DD slash YYYY

SSN

Any tickets or accidents in the last 5 years?

Date

Description

Drivers License #

Drivers License

Relationship to you

Spouse

Child

Parent

Other

Occupation

Any tickets or accidents in the last 5 years?

Date

Description

Driver #3

Name

First Last

Phone

Date of Birth

Month

Day

Year

SSN

Drivers License

Relationship to you

Spouse

Child

Parent

Other

Occupation

Student

Yes

Good Student Disocunt (GPA)

Any tickets or accidents in the last 5 years?

Date

Description

Driver #4

Name

First Last

Phone

Date of Birth

MM slash DD slash YYYY

SSN

Drivers License

Relationship to you

Spouse

Child

Parent

Other

Occupation

Student

Yes

Good Student Disocunt (GPA)

Any tickets or accidents in the last 5 years?

Date

Description

Driver #5

Name

First Last

Phone

Date of Birth

MM slash DD slash YYYY

SSN

Drivers License

Relationship to you

Spouse

Child

Parent

Other

Occupation

Student

Yes

Good Student Disocunt (GPA)

Any tickets or accidents in the last 5 years?

Date

Description

Current Auto Policy Information

Liability Limits

$25,000/$50,000/$25,000

$50,000/$100,000/$50,000

$100,000/$300,000/$100,000

$250,000/$500,000/$250,000

$500,000/$500,000/$500,000

UM/UIM

$25,000/$50,000/$25,000

$50,000/$100,000/$50,000

$100,000/$300,000/$100,000

$250,000/$500,000/$250,000

Decline

Med Pay

$1,000

$5,000

$10,000

$25,000

Do you currently have Gap Coverage?

Yes

Current Auto Insurer Name

Current Policy Expiration Date

MM slash DD slash YYYY

Length of Time with Current Auto Insurer

Towing/Rental Reimbursement

Yes

Current Monthly Auto Premium

Pay Plan Preferred

Rental Property

Rental Property Address

Street Address Address Line 2 City State ZIP Code

County

Short-term rental? (VRBO, Air BnB, etc.)

Days rented per year

Occupany Status

Days owner occupied per year

Personal Property Coverage Requested

Year Built

Under Construction?

Square Feet

Stories

Construction Type

What type of siding?

Roof Type

Age of roof

Foundation

Garage

Garage Type

# of baths

Any unfinished areas in your home?

Please specify the unfinished area(s)

Floor Type

Wood %

Carpet %

Ceramic %

Vinyl %

Laminate %

OTHER (FILL IN)

Fireplace

Wood Burning Stove

Was this installed by a professional?

Central Heat/Air

Heat/Air Type?

Alarm

Smoke alarm

Dead bolt

Monitored fire & burglar alarm

Responding Fire Dept.

Miles to Fire Dept.

Animals

What kind of animals?

Trampoline

Trampoline Safety

Fenced

Netting

Swimming Pool

Pool Safety

Fenced

Locked

Condition of home

Current Carrier

Motorcycle/ATV

Name of Primary Driver

First Last

Was vehicle purchased new?

Yes

Current Carrier

Drivers License

Licensed Motorcycle Endorsement

Yes

Has Driver Completed Safety Course?

Yes

Tickets or accidents in last 5 years?

Years Experience

Vehicle Type

Motorcycle

Slingshot

ATV

Number of Wheels

Usage

Year

Make

Model

VIN

CC's

Current Carrier

Umbrella

In 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.

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?

Do you own any of the following items?

Boat/Yacht

Motorcycle

ATV

Golf Cart

Vacant Land

Business

Boat Information

Number of Watercraft looking to Insure:

Primary Operator

First Last

Years boating experience

Other Operator Information

Name

Date of Birth

Marital Status

Years Experience

List any operator in or outside the household with regular access to insured watercraft more than 12 times per year

Current Carrier

Expiration Date

MM slash DD slash YYYY

Boat #1

HIN #

Year

Make

Model

Boat Value

Include value of permanent/portable boating equipment

Purchase Price

Year Purchased

Propulsion type

Inboard

Outboard

Inboard/Outboard

Jet

Non-powered

Number of engines

Boat Length

Hull material

Total horsepower

Excluding trolling and kicker motors

Maximum Speed

MPH

Enhanced performance modifications

Blowers, superchargers, etc.

Is boat used for racing?

Storage zip code

Where is boat stored?

Do you own a boat trailer?

Value of trailer

Year purchased

Multi-Owner

More than one owner, not in the same household

Boat #1 Coverage Information

Hull Coverage (Comp & Collision)

Hull Deductible (Comp & Collision)

Liability coverage limit

Roadside Assistance

Uninsured/Underinsured Boater Coverage

Medical Payments Coverage

Fishing Equipment Coverage

Primary Personal Effects Coverage

Boat #2

Year

Make

Model

Boat Value

Include value of permanent/portable boating equipment

Purchase Price

Year Purchased

HIN #

Propulsion type

Inboard

Outboard

Inboard/Outboard

Jet

Non-powered

Number of engines

Boat Length

Hull material

Total horsepower

Excluding trolling and kicker motors

Maximum Speed

MPH

Enhanced performance modifications

Blowers, superchargers, etc.

Is boat used for racing?

Storage zip code

Where is boat stored?

Do you own a boat trailer?

Value of trailer

Year purchased

Multi-Owner

More than one owner, not in the same household

Boat #2 Coverage Information

Hull Coverage (Comp & Collision)

Hull Deductible (Comp & Collision)

Liability coverage limit

Roadside Assistance

Uninsured/Underinsured Boater Coverage

Medical Payments Coverage

Fishing Equipment Coverage

Primary Personal Effects Coverage

Boat #3

Year

Make

Model

Boat Value

Include value of permanent/portable boating equipment

Purchase Price

Year Purchased

HIN #

Propulsion type

Inboard

Outboard

Inboard/Outboard

Jet

Non-powered

Number of engines

Boat Length

Hull material

Total horsepower

Excluding trolling and kicker motors

Maximum Speed

MPH

Enhanced performance modifications

Blowers, superchargers, etc.

Is boat used for racing?

Storage zip code

Where is boat stored?

Do you own a boat trailer?

Value of trailer

Year purchased

Multi-Owner

More than one owner, not in the same household

Boat #3 Coverage Information

Hull Coverage (Comp & Collision)

Hull Deductible (Comp & Collision)

Liability coverage limit

Roadside Assistance

Uninsured/Underinsured Boater Coverage

Medical Payments Coverage

Fishing Equipment Coverage

Primary Personal Effects Coverage

Golf Cart

Year

Make

Model

Primary Use

Transportation

Golfing

Fuel Type

Electric

Gas

Recreational Vehicle

Years RV Operating Experience

RV Type

Motor Home

Travel Trailer

Year

Manufacturer

Model/Series

Body Style

Value of RV

Length of Ownership

Garaging Zip Code

Vehicle Use

< 30 Days

30-150 Days

> 150 Days

Primary Residence

RV (Full Timer)

Yes

Prior RV Insurance

Yes

Prior Carrier

Expiration Date

MM slash DD slash YYYY

Settlement Options

Total Loss Replacement (new RVs up to two model years old)

Actual Cash Value

Agreed Value

Physical Damage Deductibles

$250

$500

$1,000

$2,500

Windshield Coverage

Yes

Medical Payments Coverage

$1,000

$2,500

$5,000

$10,000

Liability Coverage Limits

Emergency Expense Coverage

$750 (included with Physical Damage)

$2,000

$7,500 (Full Timer’s only)

UM/UIM Coverage Limits

Vacation Liability ($10,000 included—up to $500,000)

Personal Effects Coverage ($1,000 – $99,000)

Roadside Assistance

Yes

Please upload current policy documents if you have them available.

Max. file size: 10 MB.

Consent(Required)

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I agree to the Cast Iron Insurance privacy policy https://castironinsurance.com/privacy-policy/ and I give Cast Iron Insurance permission to contact me by phone, email and text message.

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Personal Lines Intake

1StakWise - PL Intake

Primary Contact Information

Spouse Information

Condo/Home Information

Detatched Structure

Flooring

Mobile Home

Detatched Structure

Flooring

Farming

Current Carrier Information

Auto Information

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

Vehicle #5

Driver #1 (Named Insured)

Driver #2

Driver #3

Driver #4

Driver #5

Current Auto Policy Information

Rental Property

Floor Type

Motorcycle/ATV

Umbrella

Boat Information

Boat #1

Boat #1 Coverage Information

Boat #2

Boat #2 Coverage Information

Boat #3

Boat #3 Coverage Information

Golf Cart

Recreational Vehicle

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