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Address: 208 New Edition Ct. Cary, NC 27511
Phone: (919) 463-5300
Email: info@lipstoneinsurance.com

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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

Did you pay off the loan on a car this year?*
Which vehicle?*
Year Make Model
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?*
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?

Do you want to make any changes to your coverage?*
Please 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?*
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?*

Is the name on the home policy the same as the one on the deed?*
What 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?*

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 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.)*

Do you own any water craft(s)?*
Please provide the water craft information*
Year Make Model HP Length Value

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)

Do you own a trampoline?*
Is it in a fenced-in yard?*
Does it have a net?*

Does you home have a pool?*
Please 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?*
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?*

Do you want to make any changes to your coverage?*
Please 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

Address: 208 New Edition Ct. Cary, NC 27511
Phone: (919) 463-5300
Email: info@lipstoneinsurance.com

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