test form

Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Email*
Do you consent to receiving text messages from the Lipstone Insurance Group?*
- Yes
- No
If 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?*
- Yes
- No
What date did you purchase or lease it?*
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 State ZIP Code
Did you trade in a vehicle when you did this?*
- No
- Yes
Which vehicle did you trade in? (Year, Make, & Model)*
How will you use the vehicle?*
Do you want collision coverage? If so, what deductible amount?*
Do you want comprehensive/other than collision coverage? If so, what deductible amount?*
Do you want Towing & Labor coverage? If so, what amount?*
Do you want Rental Car Reimbursement coverage? If so, what amount?*
Do you want Repair/Replacement coverage? (Only available for brand new vehicles purchased in the last 60 days)*

Do you have any new drivers in your household that are not listed on your policy?*
New Driver Information
First Name Last Name Date of Birth State & License Number Social Security Number Date 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?*
Who is the driver, which vehicle, & how are they using the vehicle?*
Driver Vehicle Auto Usage

Are any of the vehicles listed on your own titled/registered besides the Named Insured(s) on the policy?*
The 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 Name Last Name Year Make Model

Does anyone who's not listed as a driver on your policy drive your vehicle?*
New Driver Information*
First Name Last Name Date of Birth State & License Number Social Security Number Date 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 Name Last Name Date of Birth State & License Number Social Security Number Date licensed (Month & Year) Which vehicle will they drive?

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?*
Have you made any additions, improvements, or renovations to your home since you last reviewed the coverage amounts on your policy?*
What kind of additions, improvements, or renovations did you make?*
How much did you spend on the additions, improvements, or renovations?*

Have you refinanced your mortgage in the last 12 months?*
What is your new mortgage company information?*
Company Name Address 1 Address 2 City State Zip Code Loan Number Escrowed

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.)*

Do you own any ATV, golf cart, or snow mobile?*
Please provide the ATV, golf cart, or snow mobile information*
Year Make Model Value

Do you own any animals?*
Please provide animal information*
Type (Dog, Cat, Snake, etc.) Breed (Golden Retriever, Lab Mix)

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?*
Please provide the property information*
Property Type Address City State Zip Code

Do you rent out your home or part of your home? (Including if you use Airbnb, VRBO, etc.)*

Your home insurance does not provide flood insurance. Would you be interested in a flood insurance proposal?*

Would you be interested in a proposal for Life or Disability Insurance?
- Life Insurance
- Disability Insurance

First Name	Last Name	Date of Birth	State & License Number	Social Security Number	Date licensed (Month & Year)	Which vehicle will they drive?

Driver	Vehicle	Auto Usage

Year	Make	Model

First Name	Last Name	Year	Make	Model