Personal Lines Intake Form - Gethsemane Financial Group, Inc.

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Named Insured (Primary) *

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Date of Birth (DOB) *

SSN (last 4) *

Additional Named Insured

Relationship/Entity Type *

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Email *

Mobile *

Mailing Address *

Address Line 1

City

State

Zip Code

Is Physical Address same? *

Physical Address (if different) *

Address Line 1

City

State

Zip Code

Preferred Contact Method *

Preferred Contact Method
Email
Text

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Best Time to Reach *

Marital Status *

Single
Married
Other

Occupation/Employer *

Household Members (Adults & Licensed Teen Drivers) *

Check all that apply *

Auto (Personal)
Homeowners (HO-5)
Condo (HO-6)
Renters (HO-4)
Umbrella/Excess
Personal Articles Floater
Flood (NFIP/Private)
Boat/Watercraft
Motorcycle/ATV
Dwelling Fire (DP)
Mobile/Manufactured Home
Classic Auto
RV
Short-Term Rental
Other

Other *

Current Carrier(s) *

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Policy no. *

Exp. Date *

Years Continuous Coverage *

Any lapse in past 5 years?

If Yes, Explain *

Prior Liability Limits (Auto / Umbrella / Home) *

Any losses in the last five (5) years? *

Insurance carriers may obtain your official loss history from reporting databases or prior insurers. Failure to disclose all losses within the past five (5) years may be considered a material misrepresentation and could affect eligibility, pricing, or the ability to offer coverage. Please answer accurately and completely

Loss History (5 years)

Date *

Line *

Cause *

At Fault? *

Paid / Reserve Amount *

Status *

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Vehicle Year *

Make/Model *

VIN *

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Garaging ZIP *

Use *

Commute
Pleasure

Miles per Year *

Comp / Coll *

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Driver Name *

DOB *

Driver License Number / State *

Years Licensed *

Violations? (3yrs) *

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SR-22 *

Marital Status *

Single
Married

Rideshare / Delivery *

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Platform *

Frequency *

Property Address *

Address Line 1

City

State

Zip Code

Occupancy *

Primary
Secondary
Rental

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Year Built *

Square Feet *

Stories *

Property Build *

Frame
Masonry
Joint Masonry
Non-Combustible
Modified or Semi-Fire Resistive
Fire Resistive

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Roof Type / Year *

Heating Type *

Updates *

Update Year *

Protection *

Smoke
CO
Sprinkler

Alarm (Central) *

Distance to Hydrant (ft) *

Distance to Fire Station(miles) *

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Pool *

Trampoline *

Dogs / Breeds *

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Solid Fuel Burner *

Short-Term Rental *

Any prior claims at this location? *

Property Claim Details

Date *

Line *

Cause *

At Fault? (copy) *

Paid / Reserve Amount *

Status *

Auto Liability (BI / PD) *

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UM / UIM *

MedPay / PIP *

Rental/Towing *

Home Coverage

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Coverage A (Dwelling) *

Coverage B *

Coverage C *

Loss of Use (D) *

Liability (E) *

MedPay (F) *

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Deductible *

Wind / Hail Deductible *

Are you requesting an Umbrella? *

Disclaimer: Umbrella coverages are subject to underlying limits determined by the carrier. If underlying falls below required limits, carrier may deny umbrella.

Do you have any high value items to add? (i.e. Jewelry, art work, instruments, etc.)

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Signed & dated application *

Click or drag a file to this area to upload.

Prior declarations pages (all lines) *