Underwriting Hub - Reed Brothers Insurance Services, Inc.

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Call In Quote

Use this form if somebody calls in requesting a quote.

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

LEAD SOURCE INFORMATION

How Did You Hear About Us?(Required)

Who Referred You?

First Name Last Name

Referral Notes

Please include relevant info on the referral - was it a current client, another insurance agent, loan officer, realtor, closing attorney, etc

Which Agent Do You Want To Work With?

WHAT IS IMPORTANT TO YOU?

(Other Than Price) What Is Most Important When It Comes To Choosing An Insurance Carrier?

(Other Than Price) What Is Most Important When It Comes To Choosing An Insurance Advisor?

LEAD TYPE | LINES OF BUSINESS

What Type Of Insurance Are You Looking For?(Required)

Personal

Business

Life Insurance | Long Term Care | Annuities?

Personal = Home, Auto, Umbrella Insurance Business = Business For A Business

INSURED | CONTACT INFORMATION

Insured Name

First Name Last Name

Business Name

Primary Business Contact

First Name Last Name

Address

Street Address Address Line 2 City State ZIP Code

Mobile Phone

Is It OK To Text You?

Gender

Male

Female

Date Of Birth

Social Security Number

If the caller doesn't want to give his/her social say the following: **If you asked if this affects the prospects Credit - it does NOT. This is an Insurance Pull, which is a "soft pull" on their credit **We can get preliminary pricing without your social, but we will need this information for final pricing**

Driver's License Number

Federal ID

Marital Status

Single

Married

Civil Union

Spouse | Partner Name

First Name Last Name

Spouse/Partner Gender

Male

Female

Spouse/Partner Date Of Birth

Spouse/Partner Social Security Number

Spouse/Partner Driver's License Number

Description Of Business (What Do You Do?)

Years In Business

Annual Revenue (If New Business = 12 Months Projected)

Number Of Employees

Annual Payroll (If New Business = 12 Months Projected)

POLICY | QUOTE INFORMATION

Personal Policy Type(s)

AUTOP

HOME

PUMBR

RENTERS

RENTAL PROPERTY

WATERCRAFT

Ask "What type of insurance can we help you with"

Business Policy Type(s)

AUTOB

BOP/CPKGE

WORK

CUMBR

HABITATIONAL

Ask "What type of insurance can we help you with"

Auto Policy Information

Current Coverage

Yes

Do you have current insurance coverage?

Current Carrier

Who is your current carrier?

Effective Date

Do You Know What Liability Limits You Currently Have?

Yes

If the current coverages & limits aren't known, we will choose options we feel are good

Bodily Injury Liability

Property Damage

Combined Single Limit

UnInsured/UnderInsured Combined Single Limit

Additional Policy Level Coverage(s)

Hired Auto

Non-Owned Auto

Driver Information

Number of Drivers (Other than Insured & Spouse / Partner)

Personal Driver 1

First Name Last Name

Date of Birth (Driver 1)

Driver's License Number (Driver 1)

Personal Driver 2

First Name Last Name

Date of Birth (Driver 2)

Driver's License Number (Driver 2)

Personal Driver 3

First Name Last Name

Date of Birth (Driver 3)

Driver's License Number (Driver 3)

Number of Commercial Drivers

Commercial Driver 1

First Name Last Name

Date of Birth (CD 1)

Driver's License Number (CD 1)

Commercial Driver 2

First Name Last Name

Date of Birth (CD 2)

Driver's License Number (CD 2)

Commercial Driver 3

First Name Last Name

Date of Birth (CD 3)

Driver's License Number (CD 3)

Commercial Driver 4

First Name Last Name

Date of Birth (CD 4)

Driver's License Number (CD 4)

Vehicle Information & Vehicle Level Coverage

Number of Vehicles

Vehicle 1 Year

Vehicle 1 Make

Vehicle 1 Model

Vehicle 1 VIN

Other Than Collision | Comprehensive Coverage

No Coverage

$0 Deductible

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Collision Coverage

No Coverage

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 / $1,500

Road Service / Towing & Labor

No Coverage

$25

$50

$100

Vehicle 2 Year

Vehicle 2 Make

Vehicle 2 Model

Vehicle 2 VIN

Other Than Collision | Comprehensive Coverage

No Coverage

$0 Deductible

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Collision Coverage

No Coverage

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 / $1,500

Road Service / Towing & Labor

No Coverage

$25

$50

$100

Vehicle 3 Year

Vehicle 3 Make

Vehicle 3 Model

Vehicle 3 VIN

Other Than Collision | Comprehensive Coverage

No Coverage

$0 Deductible

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Collision Coverage

No Coverage

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 / $1,500

Road Service / Towing & Labor

No Coverage

$25

$50

$100

Vehicle 4 Year

Vehicle 4 Make

Vehicle 4 Model

Vehicle 4 VIN

Other Than Collision | Comprehensive Coverage

No Coverage

$0 Deductible

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Collision Coverage

No Coverage

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 / $1,500

Road Service / Towing & Labor

No Coverage

$25

$50

$100

Enter Misc Auto Information

Upload Any Auto Insurance Files You May Have

Drop files here or

Max. file size: 300 MB.

Home Information

New Purchase Or Existing Home

New Home Purchase

Existing Home

Closing Date

Loan Officer Name

First Name Last Name

Loan Officer Email

Loan Officer Mobile Phone

Realtor Name

First Name Last Name

Realtor Email

Realtor Mobile Phone

Previous Address

Street Address City State ZIP Code

Effective Date

Current Carrier

Purchase Price

What Type Of Home?

Single Family

Townhome

Condo

Does The HOA Cover The Shell?

Yes

New Construction

Yes

Year Built

Is House Older Than 20 Years

Yes

If House Older Than 20 Years - Year Of Roof Update

If House Older Than 20 Years - Year Of Electric Update

If House Older Than 20 Years - Year Of Plumbing Update

If House Older Than 20 Years - Year Of HVAC Update

Construction Of Home

Frame

Brick Veneer

Log

Other

Square Footage

Number Of Stories

Foundation Type

Slab

Crawl Space

Basement - Unfinished

Basement - Partial Finish

Basement - Finished

Elevated

Homeowner's Coverage Information

Dwelling Coverage Amount

Deductible

$1,000

$1,500

$2,500

$5,000

Personal Liability

$1,000,000

$500,000

$300,000

Medical Payments To Others

$1,000

$2,000

$5,000

$10,000

Enter Misc Homeowner's Info

Upload Any Homeowner's Files You May Have

Drop files here or

Max. file size: 300 MB.

Renters Insurance

Effective Date

Contents Coverage Amount

Deductible

$1,000

$1,500

$2,500

$5,000

Personal Liability

$1,000,000

$500,000

$300,000

Medical Payments To Others

$1,000

$2,000

$5,000

$10,000

Business Owners Information

Effective Date

Current Coverage

Yes

Current Carrier

BOP Coverage Types

General Liability Only (GL)

GL + Building Coverage

GL + Business Contents

GL + Building + Business Contents

Number of Location(s)/Building(s)

Same As Mailing Addres

Main Address (Other Than Mailing)

Add'l Locations (Other Than Primary)

Enter # of Locations/Buildings (if more than 2 please enter information in "Multiple Location | Building Info" Section

Primary Location Address

Street Address City State ZIP Code

Multiple Location | Building Info

Enter Any Address Info | Coverage Info as notes

Business Owners Coverage Information

General Liability Limits

$1,000,000 | $2,000,000

$500,000 | $1,000,000

$300,000 | $600,000

Building Coverage

Business Personal Property Coverage

Optional Coverage (Select All That Apply)

Cyber Liability

Employment Practices Liability

Professional Liability

Enter Misc BOP | CPKG Info

Upload Any BOP | CPKG Files

Drop files here or

Max. file size: 300 MB.

Workers Compensation Information

Effective Date

Current Coverage

Yes

Current Carrier

Number Of Class Codes

Class Code (Main)

If you don't have/know the Code - please enter description

Class Code Payroll (Main)

Class Code (2)

If you don't have/know the Code - please enter description

Class Code Payroll (2)

Class Code (3)

If you don't have/know the Code - please enter description

Class Code Payroll (3)

Workers Compensation Coverage Information

Workers Compensation Limit

$1,000,000 | $1,000,000 | $1,000,000

$500,000 | $500,000 | $500,000

$100,000 | $500,000 | $100,000

Enter Misc Workers Compensation Information

Upload Misc Workers Compensation Files

Drop files here or

Max. file size: 300 MB.

Personal Umbrella Coverage

Effective Date

Current Coverage

Yes

Current Carrier

Personal Umbrella Limit

Enter Misc Personal Umbrella Information

Enter any misc info (ex. Underlying Coverage(s) and rating info not already entered)

Upload Personal Umbrella Files

Drop files here or

Max. file size: 300 MB.

Commercial Umbrella Coverage

Effective Date

Current Coverage

Yes

Current Carrier

Commercial Umbrella Limit

Enter Misc Commercial Umbrella Information

Enter any misc info (ex. Underlying Coverage(s) and rating info not already entered)

Habitational | Rental Property Information

Effective Date

Current Coverage

Yes

Current Carrier

Habitational | Rental Property Coverage

Number of Location(s) | Building(s)

More Than 1

If More than 1 location or building - please enter information in "Enter More Location Information" Section or upload current Dec Pages in the Upload File Section

Location Address

Street Address City State ZIP Code

Building Coverage

Year Built

Square Footage

Number of Families Per Building

1 (Single Family)

2 (Duplex)

5-10

11-20

20+

Construction

Frame

Masonry Veneer

Joisted Masonry

Masonry Non-Combustible

Non-Combustible

Number of Stories

Sprinklered

Yes

Enter More Location Information

Enter Misc Habitational | Rental Property Information

Upload Habitational | Rental Property Files

Drop files here or

Max. file size: 300 MB.

Upload Bond | Surety Misc Files

Drop files here or

Max. file size: 300 MB.

MISC Notes

Call In Quote

LEAD SOURCE INFORMATION

WHAT IS IMPORTANT TO YOU?

LEAD TYPE | LINES OF BUSINESS

INSURED | CONTACT INFORMATION

POLICY | QUOTE INFORMATION

Auto Policy Information

Driver Information

Vehicle Information & Vehicle Level Coverage

Home Information

Homeowner's Coverage Information

Renters Insurance

Business Owners Information

Business Owners Coverage Information

Workers Compensation Information

Workers Compensation Coverage Information

Personal Umbrella Coverage

Commercial Umbrella Coverage

Habitational | Rental Property Information

Habitational | Rental Property Coverage

About Reed Brothers Insurance Services, Inc.

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