Personal Intake Form

Step 1 of 21

Name

First Last

Phone

Drivers License

Date of Birth

SSN

Occupation

Marital Status

Single

Married

Divorced

Widowed

Referred By Name

First Last

Current Address (No PO Boxes)

Street Address Address Line 2 City State ZIP Code

Address of Property Being Purchased

Same as current address

Street Address Address Line 2 City State ZIP Code

Would you like to add a different mailing address?

Yes

Mailing Address

Street Address Address Line 2 City State ZIP Code

Driver #2

Name(Required)

First Last

Phone

Date of Birth(Required)

Drivers License

Occupation

Relationship to you(Required)

Spouse

Child

Parent

Other

Driver #3

Name(Required)

First Last

Phone

Date of Birth(Required)

Drivers License

Occupation

Relationship to you(Required)

Spouse

Child

Parent

Other

Driver #4

Name(Required)

First Last

Phone

Date of Birth(Required)

Drivers License

Occupation

Relationship to you(Required)

Spouse

Child

Parent

Other

Driver #5

Name(Required)

First Last

Phone

Date of Birth(Required)

Drivers License

Occupation

Relationship to you(Required)

Spouse

Child

Parent

Other

Investment Property

Address(Required)

Street Address Address Line 2 City State ZIP Code

Property Status(Required)

Currently Occupied with Tenants

Listed For Sale - No Occupants

Listed For Rent - No Occupants

Undergoing Renovations - Vacant

Motorcycle/Slingshot/ATV

Name of Primary Driver(Required)

First Last

Vehicle Type(Required)

Motorcycle

Slingshot

ATV

Is Vehicle Used for Racing?(Required)

Yes

Current Motorcycle License(Required)

Yes

Has Driver Completed Safety Course?(Required)

Yes

Year(Required)

Make(Required)

Model(Required)

VIN

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.(Required)

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?(Required)

This includes primary, secondary, vacation, rental and investment properties.

How many home/renters claims have you made in the last 5 years?(Required)

How many vehicles do you own?(Required)

How many auto claims have you made in the last 5 years?(Required)

Any drivers on your auto policy have an at-fault accident in the last 5 years?(Required)

Yes

Do you own any of the following items?(Required)

Boat/Yacht

Motorcycle

ATV

Golf Cart

Vacant Land

Business

Golf Cart

Year

Make

Model

Primary Use

Transportation

Golfing

Fuel Type

Electric

Gas

Recreational Vehicle

RV Type

5th Wheel

Motorcoach

Other

Year

Make

Model

Please upload current policy documents if you have them available.

Max. file size: 98 MB.

Consent(Required)

The Oak Insurance Group may contact me via phone call, email and text message.

I consent to The Oak Insurance Group's privacy policy.https://www.theoakinsurancegroup.com/privacy-policy-3/

Dolan and his team at The Oak Insurance Group made the process of updating our business insurance very easy. They asked thoughtful questions to...

a month ago

Kelsey Greene

I’ve had worked with Steven Bott twice looking for house insurance and it was truly an amazing experience! He made it so easy and simple...

Angel Phammy

My wife and I have loved working with Steven Bott at the Oak Insurance Group. He has taken care of all of our home and...

4 months ago

Phillip Bates

Dolan is an incredible and responsive agent and treats you like you are family. He recommends only what he would do to protect his...

7 months ago

Cristy Jordan

Steven made setting up my new policy as easy and quick as possible. He’s been very responsive as well as effective and I can’t say...

Ariam Yohannes

Driver #2

Vehicle #2

Driver #3

Vehicle #3

Driver #4

Vehicle #4

Driver #5

Vehicle #5

Investment Property

Motorcycle/Slingshot/ATV

Umbrella

Boat Information

Golf Cart

Recreational Vehicle

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