Jane Doe – Mortgage Lender Referral Partner

Contact Info:

Name: Jane Doe
Company: Prime Lending Solutions
Phone: (555) 987-6543
Email: jane.doe@primelending.com
Website: www.primelending.com

Social Media:

Instagram: @janedoelender
LinkedIn: Jane Doe LinkedIn

Specialties:

FHA, VA, & Conventional Loans
First-Time Homebuyers
Refinancing & Home Equity Loans
Jumbo Loans
Investment Property Financing

Service Area: Serving clients nationwide

About Jane:
With over 15 years in the lending industry, Jane Doe specializes in providing personalized mortgage solutions to fit her clients’ unique needs. She prides herself on clear communication, transparent processes, and ensuring each borrower feels informed and confident every step of the way. Whether you’re purchasing your first home or refinancing your current property, Jane is committed to finding the best loan options and rates for you.

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Types of Insurance*

Home

Renters

Auto

Motorcycle

Valuable Items

Boat

Umbrella

RV Trailer or Camper

Date Policies Should Start*

MM slash DD slash YYYY

How were you referred to us?

Primary Applicant

Primary Insured Name*

First Last

Date of Birth*

Month

Day

Year

Gender*

Email*

Phone*

Can we text you?

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Drivers License Number*

Drivers License State*

Motorcycle Endorsement?

Yes

Marital Status

Education Level

Occupation

Is there a Co-Applicant?

Yes

Co-Applicant

Co-Insured Name*

First Last

Co-Insured Date of Birth*

Month

Day

Year

Co-Insured Gender*

Co-Insured Email

Co-Insured Phone

Can we text co-insured?

Co-Insured Drivers License Number

Co-Insured Drivers License State

Co-Insured Motorcycle Endorsement?

Yes

Co-Insured Education Level

Co-Insured Occupation

Current Address

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Current Address*

Same as Mailing Address

Street Address Address Line 2 City State ZIP Code

Property Information

Property Address*

Same as Current Address

Street Address Address Line 2 City State ZIP Code

Property Map

Type of Home*

Primary Use For Home*

How many weeks per year will the property be rented?*

How long will the property be vacant at one time?*

Is there a caretaker?*

Yes

Primary Occupancy*

Is property titled in a name Other Than your personal name(s)?*

Example: Trust, LLC, Corporation, Partnership, etc.

Yes

Name on Title of Property*

Is this a New Purchase?

Yes

Purchase Date*

MM slash DD slash YYYY

Purchase Price

Will you do a major renovation on this property shortly after you purchase it?

Yes

Will there be a Mortgage?*

Yes

Are there multiple dwellings on this property?

Yes

Additional Property Coverage Interests

None

Flood

Earthquake

Hurricane

Do you have any home insurance policy currently?

Yes

Name of current home insurance company

Have Dogs?

Yes

Breed(s) of Dog(s)

Any dogs have bite history?*

Yes

Home Information

Is home newly built?

Yes

Home Currently Under Construction?*

Yes

Year Built*

Square Feet*

# of Bedrooms

# of Bathrooms

# of Stories

Construction Type

Roof Type

Foundation Type

Garage Type

Garage Number of Vehicles

Security System

Primary Heating Type

Does Home Have Central AC?

Yes

Number of Water Heaters

Where is the water heater located?

Has Pool?*

Yes

Has Wood Burning Stove?*

Yes

Has Fireplace?*

Yes

Pool Type*

In Ground

Above Ground

Is Pool Fenced?*

Yes

Does pool have a diving board?*

Yes

Has there been any updates to the Roof, Plumbing, Heating, or Electrical?

Yes

Roof Update Year

Roof Update Level

Plumbing Update Year

Plumbing Update Level

Heating Update Year

Heating Update Level

Electrical Update Year

Electrical Update Level

Solar Panels?

Yes

Number of Solar Panels

Value of Solar Panels

Does your home qualify for discounts?

(Check all that apply)

Deadbolts

Fire Extinguisher

Smoke Alarm

Monitored Smoke Alarm

Monitored Burglar Alarm

Gated Community

Perimeter Gate

Mature Age

Interior Sprinklers

Backup Generator

Gas Leak Detector

Water Leak Detector

Live-in Caretaker

Lightning Protection

Water Flow Alarm

Patrolled

24/7 Guard

CCTV

Doorman

Motion Detector

Wind Mitigation

Impact Resistant Glass

Mortgage Free

Military

First Responder

Signal Continuity

Does home have any detached structures?

Yes

What types of detached structures?

Guest House

Pool House

Shed

Workshop

Deck

Other

Other type of detached structure

Does home have an elevator?

Yes

Any trampoline?

Yes

Any domestic employees?

Yes

Photos of Home (Optional)

If you would like to attach any pictures of your home inside and/or outside, please do so here.

Drop files here or

Max. file size: 3 MB, Max. files: 6.

Valuable Items

Most home insurance policies allow you to schedule valuable items to your policy such as jewelry, fine art, firearms, antiques, bikes, cameras, certain electronics, collectibles, musical instruments, silverware, etc. If you would like to include any of these items, please do so below. If an item is ineligible for scheduling to your policy we will let you know.

6. Driver Name*

First Last

6. Driver Date of Birth*

MM slash DD slash YYYY

6. Gender*

6. Driver License #*

6. Drivers License State*

6. Relationship to Insured*

Vehicle 1

1. VIN

1. Year*

1. Make*

1. Model*

1. Estimated Annual Miles

1. Primary Use

1. Ownership

Own

Lease

1. Vehicle Financed

Yes

1. Miles driven one-way to work

1. Days per week driven to work

1. Preferred COMPREHENSIVE Deductible*

1. Preferred COLLISION Deductible*

1. Name of Primary Driver

Add 2nd Vehicle

Add a Vehicle

Vehicle 2

2. VIN

2. Year*

2. Make*

2. Model*

2. Estimated Annual Miles

2. Primary Use

2. Ownership

Own

Lease

2. Vehicle Financed

Yes

2. Miles driven one-way to work

2. Days per week driven to work

2. Preferred COMPREHENSIVE Deductible*

2. Preferred COLLISION Deductible*

2. Name of Primary Driver

Add 3rd Vehicle

Add a Vehicle

Vehicle 3

3. VIN

3. Year*

3. Make*

3. Model*

3. Estimated Annual Miles

3. Primary Use

3. Ownership

Own

Lease

3. Vehicle Financed

Yes

3. Miles driven one-way to work

3. Days per week driven to work

3. Preferred COMPREHENSIVE Deductible*

3. Preferred COLLISION Deductible*

3. Name of Primary Driver

Add 4th Vehicle

Add a Vehicle

Vehicle 4

4. VIN

4. Year*

4. Make*

4. Model*

4. Estimated Annual Miles

4. Primary Use

4. Ownership

Own

Lease

4. Vehicle Financed

Yes

4. Miles driven one-way to work

4. Days per week driven to work

4. Preferred COMPREHENSIVE Deductible*

4. Preferred COLLISION Deductible*

4. Name of Primary Driver

Add 5th Vehicle

Add a Vehicle

Vehicle 5

5. VIN

5. Year*

5. Make*

5. Model*

5. Estimated Annual Miles

5. Primary Use

5. Ownership

Own

Lease

5. Vehicle Financed

Yes

5. Miles driven one-way to work

5. Days per week driven to work

5. Preferred COMPREHENSIVE Deductible*

5. Preferred COLLISION Deductible*

5. Name of Primary Driver

Add 6th Vehicle

Add a Vehicle

Vehicle 6

6. VIN

6. Year*

6. Make*

6. Model*

6. Annual Miles Driven

6. Primary Use

6. Ownership

Own

Lease

6. Vehicle Financed

Yes

6. Miles driven one-way to work

6. Days per week driven to work

6. Preferred COMPREHENSIVE Deductible*

6. Preferred COLLISION Deductible*

6. Name of Primary Driver

Add 7th Vehicle

Add a Vehicle

Vehicle 7

7. VIN

7. Year*

7. Make*

7. Model*

7. Annual Miles Driven

7. Primary Use

7. Ownership

Own

Lease

7. Vehicle Financed

Yes

7. Miles driven one-way to work

7. Days per week driven to work

7. Preferred COMPREHENSIVE Deductible*

7. Preferred COLLISION Deductible*

7. Name of Primary Driver

Add 8th Vehicle

Add a Vehicle

Vehicle 8

8. VIN

8. Year*

8. Make*

8. Model*

8. Annual Miles Driven

8. Primary Use

8. Ownership

Own

Lease

8. Vehicle Financed

Yes

8. Miles driven one-way to work

8. Days per week driven to work

8. Preferred COMPREHENSIVE Deductible*

8. Preferred COLLISION Deductible*

8. Name of Primary Driver

Add 9th Vehicle

Add a Vehicle

Vehicle 9

9. VIN

9. Year*

9. Make*

9. Model*

9. Annual Miles Driven

9. Primary Use

9. Ownership

Own

Lease

9. Vehicle Financed

Yes

9. Miles driven one-way to work

9. Days per week driven to work

9. Preferred COMPREHENSIVE Deductible*

9. Preferred COLLISION Deductible*

9. Name of Primary Driver

Add 10th Vehicle

Add a Vehicle

Vehicle 10

10. VIN

10. Year*

10. Make*

10. Model*

10. Annual Miles Driven

10. Primary Use

10. Ownership

Own

Lease

10. Vehicle Financed

Yes

10. Miles driven one-way to work

10. Days per week driven to work

10. Preferred COMPREHENSIVE Deductible*

10. Preferred COLLISION Deductible*

10. Name of Primary Driver

Special Motorcycle Coverages

Enhanced Injury Protection

Yes

Physical Damage

Actual Cash Value

None - Liability Only

Roadside Assistance

None

Roadside

Roadside w/ Trip Interruption

Carried Contents

None

$1,000

$2,000

$3,000

Accessories Coverage

Safety & Riding Apparel

Transport Trailer Coverage?

Yes

Trailer Value

Boat Information

Serial Number*

Year*

Make*

Model*

Hull ID Number

Boat Registration Number

This is the ID number assigned to your boat by the state.

Hull Material

Number of Motors

Propulsion Type

Max Horsepower

Max Speed

Current Value

Fishing Equipment Coverage

Insure the Trailer?

Yes

RV, Trailer, or Camper Information

Year*

Make*

Model*

VIN

Length (in feet)*

Please enter a number greater than or equal to 2.

Year Purchased*

Value (estimated ACV)*

Garaging Zipcode*

Number of days RV used per year*

Original Owner?*

Yes

Is there a lienholder?*

Yes

RV Lienholder Name

Is RV parked at a single location year round?*

Yes

Is RV rented commercially or used for business purposes?*

Yes

Is RV rented out to others?*

Yes

Is RV taken to/from work or used at a work location?*

Yes

Umbrella Coverage Information

Number of Properties

Number of Vehicles

Number of Watercraft

Number of Drivers

Number of Drivers (under age 25)

Number of Drivers (over age 75)

Liability Limit

Wrapping Up

Any Claims in the Past Three (3) Years?*

Yes

Please describe past claims*

Any lapse in Home insurance in the past year?

Yes

Not Applicable

Any lapse in Auto insurance in the past year?

Yes

Not Applicable

Do you need any SR-22 filings?*

Yes

Do you have any auto insurance currently?

Yes

Name of current auto insurance company

Additional Comments

Attach Documents, Images, or Other Files

Drop files here or

Max. file size: 12 MB.

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Would you like to create a user account?

Yes

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Consent*

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Referral Partner

Jane Doe – Mortgage Lender

Contact Info:

Social Media:

Specialties:

Primary Applicant

Co-Applicant

Current Address

Property Information

Home Information

Valuable Items

Additional Drivers

Additional Driver 1

Additional Driver 2

Additional Driver 3

Additional Driver 4

Additional Driver 5

Additional Driver 6

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

Vehicle 7

Vehicle 8

Vehicle 9

Vehicle 10

Special Motorcycle Coverages

Boat Information

RV, Trailer, or Camper Information

Umbrella Coverage Information

Wrapping Up

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