Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Do you consent to receiving text messages from the Lipstone Insurance Group?*YesNoIf you wish to opt out of receiving text messages in the future, then please notify us in writing by emailing us at info@lipstoneinsurance.com. Which policy(ies) are renewing with us?* Auto Home Have you purchased or leased a new car that is not on your auto policy?*YesNoWhat date did you purchase or lease it?* Date Format: MM slash DD slash YYYY Who is the vehicle titled/registered to?* First Last If you financed or leased it, then what’s the company name and address? Company Name Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Did you trade in a vehicle when you did this?*NoYesWhich vehicle did you trade in? (Year, Make, & Model)*How will you use the vehicle?*Drive to Work/School More Than 10 milesDrive to Work/School Less Than 10 milesDrive for work/my businessPleasure useDo you want collision coverage? If so, what deductible amount?*$1000$500$250$100NoneDo you want comprehensive/other than collision coverage? If so, what deductible amount?*$1000$500$250$100$0NoneDo you want Towing & Labor coverage? If so, what amount?*$100$50NoneDo you want Rental Car Reimbursement coverage? If so, what amount?*$50/$1500$30/$900NoneDo you want Repair/Replacement coverage? (Only available for brand new vehicles purchased in the last 60 days)*YesNo Do you have any new drivers in your household that are not listed on your policy?*YesNoNew Driver InformationFirst NameLast NameDate of BirthState & License NumberSocial Security NumberDate licensed (Month & Year)Which vehicle will they drive? Did you, or anyone in your household, change jobs or how far you drive one way to work?*YesNoWho is the driver, which vehicle, & how are they using the vehicle?*DriverVehicleAuto Usage Did you pay off the loan on a car this year?*YesNoWhich vehicle?*YearMakeModel Do you use your vehicle for Uber, Lyft, delivery, or business?* Uber Lyft Delivery Business None of the above Are any of the vehicles listed on your own titled/registered besides the Named Insured(s) on the policy?*YesNoThe Named Insured is the person(s) listed on the declaration page. Generally this is you and your spouse/significant other. If you have questions, then please let us know.Which vehicle(s)?*First NameLast NameYearMakeModel Does anyone who's not listed as a driver on your policy drive your vehicle?*YesNoNew Driver Information*First NameLast NameDate of BirthState & License NumberSocial Security NumberDate licensed (Month & Year)Which vehicle will they drive? Please list any drivers with their name, date of birth, NC driver's license, and Social Security Number that are NOT listed on your auto policy.First NameLast NameDate of BirthState & License NumberSocial Security NumberDate licensed (Month & Year)Which vehicle will they drive? Do you want to make any changes to your coverage?*YesNoPlease tell us what changes you'd like to make Would you be interested in a proposal for Life or Disability Insurance? Life Insurance Disability Insurance Have you moved or sold your home in the past 12 months?*YesNoHave you made any additions, improvements, or renovations to your home since you last reviewed the coverage amounts on your policy?*YesNoWhat kind of additions, improvements, or renovations did you make?*How much did you spend on the additions, improvements, or renovations?* Is the name on the home policy the same as the one on the deed?*YesNoWhat is the name(s) on the deed of the home?* What year was your roof replaced?*What year was your heating unit replaced?* Have you paid off your mortgage in the last 12 months?*YesNo Have you refinanced your mortgage in the last 12 months?*YesNoWhat is your new mortgage company information?*Company NameAddress 1Address 2CityStateZip CodeLoan NumberEscrowed Do you own any of the following items that exceed $1000 in value? (Please select all that apply)* Artwork Firearms Furs Golf clubs Jewelry Do you work, maintain, or operate a business or keep samples for your business in your home? (Please include baby-sitting, daycare, lawn care, Lularoe, Rodan + Fields, etc.)*YesNo Do you own any water craft(s)?*YesNoPlease provide the water craft information*YearMakeModelHPLengthValue Do you own any ATV, golf cart, or snow mobile?*YesNoPlease provide the ATV, golf cart, or snow mobile information*YearMakeModelValue Do you own any animals?*YesNoPlease provide animal information*Type (Dog, Cat, Snake, etc.)Breed (Golden Retriever, Lab Mix) Do you own a trampoline?*YesNoIs it in a fenced-in yard?*YesNoDoes it have a net?*YesNo Does you home have a pool?*YesNoPlease select all that apply to your pool* In a fenced-in yard Has locking gate for fence Diving board Slide In-ground Above ground Does your home have any of the following?* Smoke detectors Dead bolt locks Fire extinguisher Alarm system Do you own any additional property such as a Second Home, Rental Property, Investment Property, or Vacant Property?*YesNoPlease provide the property information*Property TypeAddressCityStateZip Code Do you rent out your home or part of your home? (Including if you use Airbnb, VRBO, etc.)*YesNo Your home insurance does not provide flood insurance. Would you be interested in a flood insurance proposal?*YesNo Do you want to make any changes to your coverage?*YesNoPlease tell us what changes you'd like to make Would you be interested in a proposal for Life or Disability Insurance? Life Insurance Disability Insurance
