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New Client Intake Information Form

New Client Intake Form

* indicates required fields

Name*

First Last

Phone Number*

Email*

Spouse or Domestic Partner Full Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Residence Type

Residence Status

Previous Address, if Length @ current address in 2 years or less:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Where Did You Hear About Francis Family Insurance?

Current FFI Agent?

Total Household Members? (Including Non-Drivers)

Quote Type*

Auto

Home

Motorcycle / Snowmobile / ATV / Golf Cart

RV / Motorhome

Boat / Personal Water Craft

Life

Enter Quotes Details Below

AUTO INSURANCE

Driver Information

How many drivers in the household?

Driver #1

Driver Name

First Last

DOB

Gender

Marital Status

License Number

Employment Status

Occupation / Employer

Health Insurance Provider

Education

Good Student(3.0 GPA or above)

Accident Information

Incident Name

Incident Type

Incident Date

Incident Name

Incident Type

Incident Date

Driver #2

Driver Name

First Last

DOB

Gender

Marital Status

License Number

Employment Status

Occupation / Employer

Health Insurance Provider

Education

Good Student(3.0 GPA or above)

Accident Information

Incident Name

Incident Type

Incident Date

Incident Name

Incident Type

Incident Date

Driver #3

Driver Name

First Last

DOB

Gender

Marital Status

License Number

Employment Status

Occupation / Employer

Health Insurance Provider

Education

Good Student(3.0 GPA or above)

Accident Information

Incident Name

Incident Type

Incident Date

Incident Name

Incident Type

Incident Date

Driver #4

Driver Name

First Last

DOB

Gender

Marital Status

License Number

Employment Status

Occupation / Employer

Health Insurance Provider

Education

Good Student(3.0 GPA or above)

Accident Information

Incident Name

Incident Type

Incident Date

Incident Name

Incident Type

Incident Date

Driver #5

Driver Name

First Last

DOB

Gender

Marital Status

License Number

Employment Status

Occupation / Employer

Health Insurance Provider

Education

Good Student(3.0 GPA or above)

Accident Information

Incident Name

Incident Type

Incident Date

Incident Name

Incident Type

Incident Date

Driver #6

Driver Name

First Last

DOB

Gender

Marital Status

License Number

Employment Status

Occupation / Employer

Health Insurance Provider

Education

Good Student(3.0 GPA or above)

Accident Information

Incident Name

Incident Type

Incident Date

Incident Name

Incident Type

Incident Date

Please add additional Driver information here (if more than 6)

Vehicle Information

How many vehicles do you have?

Vehicle #1

Year

Make

Model

VIN

Vehicle Usage

Miles to/from Work?

How long have you had this vehicle(yrs)

Do you own, finance or lease?

Current Comprehensive Deductible?

Current Collision Deductible?

Vehicle #2

Year

Make

Model

VIN

Vehicle Usage

Miles to/from Work?

How long have you had this vehicle(yrs)

Do you own, finance or lease?

Current Comprehensive Deductible?

Current Collision Deductible?

Vehicle #3

Year

Make

Model

VIN

Vehicle Usage

Miles to/from Work?

How long have you had this vehicle(yrs)

Do you own, finance or lease?

Current Comprehensive Deductible?

Current Collision Deductible?

Vehicle #4

Year

Make

Model

VIN

Vehicle Usage

Miles to/from Work?

How long have you had this vehicle(yrs)

Do you own, finance or lease?

Current Comprehensive Deductible?

Current Collision Deductible?

Vehicle #5

Year

Make

Model

VIN

Vehicle Usage

Miles to/from Work?

How long have you had this vehicle(yrs)

Do you own, finance or lease?

Current Comprehensive Deductible?

Current Collision Deductible?

Vehicle #6

Year

Make

Model

VIN

Vehicle Usage

Miles to/from Work

How long have you had this vehicle(yrs)

Do you own, finance or lease?

Current Comprehensive Deductible?

Current Collision Deductible?

Please add additional Vehicle information here (if more than 6)

Current Insurance

Current Insurance Company

Effective Date

Expiration Date

Number of Months With Prior Company

Current Bodily Injury Liability

Personal Injury Protection (PIP)

Uber / Lyft / Other Rideshare?

GrubHub / Other Delivery?

Notes

HOME INFORMATION

Type of Homeowner Insurance ?

Home Usage

Location Address (If different than mailing)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Purchase / Rental Agreement Date?

Year Built

Number of Stories

Square Footage

Construction Type

Basement Type

Basement Percent Finished

Majority Exterior Type

Number of Garages

Garage Type

Roof Shape

Roof Type

Most Recent Roof Update (Year)

Full Baths

Half Baths

Heating Type

Central Air ?

Heating/Cooling Update (Year)

Any secondary heating device?

Plumbing Update (Year)

Fireplace

Electrical System Update (year)

Number of Animals

Animal Type / Breed Of Dog(s)

Bite History?

Yes

Swimming Pool

Fenced

Trampoline

Netted

Reporting Fire Dept:

Miles from Dept:

Distance to Hydrant:

Number of Smoke Detectors?

Fire Alarm?

In Home Sprinklers?

Fire Extinguisher?

Burglar Alarm?

Gated Community?

Prior Insurance

Number of Mortgages / Home Loans

Current Carrier

Expiration Date

Effective Date

Number of Months Of Prior Coverage

Annualized Premium

Notes

MOTORCYCLE

Motorcycle Information

Number of Motorcycles / ATV's / Snowmobiles / Golf Carts

Year #1

Vehicle Year:

Vehicle Make:

Vehicle Model:

Number of CC's:

Serial #:

Value:

Year #2

Vehicle Year:

Vehicle Make:

Vehicle Model:

Number of CC's:

Serial #:

Value:

Year #3

Vehicle Year:

Vehicle Make:

Vehicle Model:

Number of CC's:

Serial #:

Value:

Driver Information

Number of Riders? (Disregard if Driver Info is Under Auto Section)

Driver #1

Driver Name

Date of Birth

Gender

Marital Status

License Number

Years of Riding Experience:

Motorcycle Endorsement?

Wear a Helmet When Riding?

Education

Employment Status

Occupation / Employer

Health Insurance Provider

Accident Information

Incident Name

Incident Type

Incident Date

Incident Name

Incident Type

Incident Date

Driver #2

Driver Name

Date of Birth

Gender

Marital Status

License Number

Years of Riding Experience:

Motorcycle Endorsement?

Wear a Helmet When Riding?

Education

Employment Status

Occupation / Employer

Health Insurance Provider

Accident Information

Incident Name

Incident Type

Incident Date

Incident Name

Incident Type

Incident Date

Driver #3

Driver Name

Date of Birth

Gender

Marital Status

License Number

Years of Riding Experience:

Motorcycle Endorsement?

Wear a Helmet When Riding?

Education

Employment Status

Occupation / Employer

Health Insurance Provider

Accident Information

Incident Name

Incident Type

Incident Date

Incident Name

Incident Type

Incident Date

Driver #4

Driver Name

Date of Birth

Gender

Marital Status

License Number

Years of Riding Experience:

Motorcycle Endorsement?

Wear a Helmet When Riding?

Education

Employment Status

Occupation / Employer

Health Insurance Provider

Accident Information

Incident Name

Incident Type

Incident Date

Incident Name

Incident Type

Incident Date

Driver #5

Driver Name

Date of Birth

Gender

Marital Status

License Number

Years of Riding Experience:

Motorcycle Endorsement?

Wear a Helmet When Riding?

Education

Employment Status

Occupation / Employer

Health Insurance Provider

Accident Information

Incident Name

Incident Type

Incident Date

Incident Name

Incident Type

Incident Date

Driver #6

Driver Name

Date of Birth

Gender

Marital Status

License Number

Years of Riding Experience:

Motorcycle Endorsement?

Wear a Helmet When Riding?

Education

Employment Status

Occupation / Employer

Health Insurance Provider

Accident Information

Incident Name

Incident Type

Incident Date

Incident Type

Incident Name

Incident Date

Please add additional Driver information here (if more than 6)

Do you want insurance for your transport trailer:

Year:

Make:

Model:

Length:

Serial #:

Value:

Has Any Cycle Been Converted To A Trike or Modified For Performance?

Address Stored (if Stored Away From Home Address):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Coverages

Comprehensive

Collision

RV/MOTORHOME

RV/Motorhome Information

Number of RV's

Year #1

Year:

Make:

Model:

Estimated Current Value:

Serial #:

Length:

Number of Slides:

Original Owner?

Number of Years Owned if not Original Owner:

Anticipated Miles Per Year Used:

Year #2

Year:

Make:

Model:

Estimated Current Value:

Serial #:

Length:

Number of Slides:

Original Owner?

Number of Years Owned if not Original Owner:

Anticipated Miles Per Year Used:

Year #3

Year:

Make:

Model:

Estimated Current Value:

Serial #:

Length:

Number of Slides:

Original Owner?

Number of Years Owned if not Original Owner:

Anticipated Miles Per Year Used:

Additional Information

Years of RVing Experience?

Address Stored (if Stored Away From Home Address):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Coverage

Notes

BOAT / PERSONAL WATER CRAFT

Boat / Personal Water Craft Information

Number of Boats/Personal Watercraft

Year #1

Boat Type:

Year:

Make:

Model:

Strength:

Serial #:

Hull ID #:

Value:

Original Owner:

Number of Years Owned if not Original Owner:

Use:

Boaters Safety Course:

Address Stored (if Stored Away From Home Address):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Engine Propulsion Type:

Engine Year:

Engine Make:

Engine Horsepower:

Engine Serial #:

Do you want insurance for your transport trailer:

Trailer Year:

Trailer Make:

Trailer Model:

Trailer Length:

Trailer Serial #:

Trailer Value:

Year #2

Boat Type:

Year:

Make:

Model:

Strength:

Serial #:

Hull ID #:

Value:

Original Owner:

Number of Years Owned if not Original Owner:

Use:

Boaters Safety Course:

Address Stored (if Stored Away From Home Address):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Engine Propulsion Type:

Engine Year:

Engine Make:

Engine Horsepower:

Engine Serial #:

Do you want insurance for your transport trailer:

Trailer Year:

Trailer Make:

Trailer Model:

Trailer Length:

Trailer Serial #:

Trailer Value:

Year #3

Boat Type:

Year:

Make:

Model:

Strength:

Serial #:

Hull ID #:

Value:

Original Owner:

Number of Years Owned if not Original Owner:

Use:

Boaters Safety Course:

Address Stored (if Stored Away From Home Address):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Engine Propulsion Type:

Engine Year:

Engine Make:

Engine Horsepower:

Engine Serial #:

Do you want insurance for your transport trailer:

Trailer Year:

Trailer Make:

Trailer Model:

Trailer Length:

Trailer Serial #:

Trailer Value:

Year #4

Boat Type:

Year:

Make:

Model:

Strength:

Serial #:

Hull ID #:

Value:

Original Owner:

Number of Years Owned if not Original Owner:

Use:

Boaters Safety Course:

Address Stored (if Stored Away From Home Address):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Engine Propulsion Type:

Engine Year:

Engine Make:

Engine Horsepower:

Engine Serial #:

Do you want insurance for your transport trailer:

Trailer Year:

Trailer Make:

Trailer Model:

Trailer Length:

Trailer Serial #:

Trailer Value:

Coverages

Comprehensive

Collision

Personal Property Coverage

Fishing Equipment Coverage

LIFE INSURANCE

Full Legal Name

Sex

Are You Currently Pregnant?

Drivers License #

Tobacco, Marijuana or Vape Use?

Height

Brief Medical History Including Any Diagnosis?

Weight

Beneficiary Information

Primary Name

DOB

Phone Number

Beneficiary Information

Contingent Name

DOB

Phone Number

This field is for validation purposes and should be left unchanged.

We Want Your Opinion!

Customer Reviews

 5/5

Nobody likes getting insurance, these guys made it easy.

Charles O

 5/5

Jason is very easy to work with. An outstanding guy!

Dave C

 5/5

No matter who helps us they are always very respectful and knowledgeable.

Kristina R

 5/5

Happy customer after one full year!

Christina C

 5/5

Francis Family has always taken care of my family’s insurance needs.

Jodi A

New Client Intake Information Form

New Client Intake Form

Enter Quotes Details Below

AUTO INSURANCE

Driver Information

Driver #1

Accident Information

Driver #2

Accident Information

Driver #3

Accident Information

Driver #4

Accident Information

Driver #5

Accident Information

Driver #6

Accident Information

Vehicle Information

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

Vehicle #5

Vehicle #6

Current Insurance

HOME INFORMATION

Prior Insurance

MOTORCYCLE

Motorcycle Information

Year #1

Year #2

Year #3

Driver Information

Driver #1

Accident Information

Driver #2

Accident Information

Driver #3

Accident Information

Driver #4

Accident Information

Driver #5

Accident Information

Driver #6

Accident Information

Coverages

RV/MOTORHOME

RV/Motorhome Information

Year #1

Year #2

Year #3

Additional Information

BOAT / PERSONAL WATER CRAFT

Boat / Personal Water Craft Information

Year #1

Year #2

Year #3

Year #4

Coverages

LIFE INSURANCE

Beneficiary Information

Nobody likes getting insurance, these guys made it easy.

Jason is very easy to work with. An outstanding guy!

No matter who helps us they are always very respectful and knowledgeable.

Happy customer after one full year!

Francis Family has always taken care of my family’s insurance needs.

Insurance

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