Personal Lines Customer Intake Form

Let’s get started! Please tell us a little bit about yourself.

Insured

Name(Required)

First Last

Address(Required)

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

Have you lived at this residence for 5+ years?(Required)

Yes

No

Prior Address(Required)

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

Phone(Required)

Date of Birth(Required)

Email Address(Required)

Preferred Contact Method(Required)

Occupation(Required)

Education(Required)

Who is your referring Agent at PrimeGroup?(Required)

Do you have a spouse?(Required)

Yes

No

Spouse

Name(Required)

First Last

Education(Required)

Date of Birth(Required)

Occupation(Required)

Have you filed for bankruptcy or foreclosure in the last 5 years?(Required)

Yes

No

Do you authorize us to run your insurance score? Insurance credit inquiries do not negatively affect your credit score.(Required)

Yes

No

Which of these coverages were you inquiring about? (Select all that apply)(Required)

Homeowner’s Insurance

Auto Insurance

Next, please tell us about your auto information.

Current Auto Carrier(Required)

Number Of Years(Required)

Effective Date(Required)

List any tickets, accidents, or claims within the past 5 years(Required)

Next, please tell us about the specific coverage options you’re requesting a quote for today.

Would you be able to provide us a copy of your current Auto Policy declaration page?(Required)

Yes

No

Upload a copy of your declaration page.(Required)

Max. file size: 512 MB.

Please upload a photo or scan of your current policy declaration page.

Bodily Injury(Required)

Property Damage(Required)

Personal Injury Protection(Required)

Medical Payments(Required)

Uninsured Motorist(Required)

Vehicle Information

Row ID	Vehicle Year	Vehicle Make	Vehicle Model	Vehicle Identification Number (VIN)	Usage (Miles driven per year)	Garage Zip Code	What is the vehicle’s primary use	What comprehensive coverage do you need?	What collision coverage do you need?	Actions

There are no Vehicles.

Driver Information

Row ID	Driver’s Name	Driver’s License Number	Driver’s Date of Birth	Driver’s License State	Driver’s License Status	Actions

There are no Drivers.

Conclusion

I understand that any submission via this website does not constitute as an agreement to bind insurance coverage and the information must be confirmed by a PGI team member via phone or email.(Required)

I AGREE

Email

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

Personal Lines Customer Information Questionnaire

Insured

Spouse

Homeowner Information

Conclusion

Tampa Bay

South Florida