Merger Bridge Portal

Homeowners Insurance Intake

Homeowners quote intake with property and dwelling details.

Submission Details

Personal Lines

Submit to Agency *

Insurance America

IA personal lines pipeline

Perkins McKenzie

PM personal lines pipeline

Your Email (IA Agent — for lead attribution)*

Your email is recorded as the submitting agent for lead attribution.

Applicant Information

First Name*

Last Name*

Date of Birth

Co-Applicant Name

Co-Applicant Date of Birth

Mailing Address

Street*

Street 2

City*

State *

ZIP*

Primary Phone*

Secondary Phone

Email Address*

Property Information

Property address same as mailing

Residence Type*

Occupancy*

Stories

Year Built*

Total Sq Ft*

Purchase Date

Purchase Price

Construction Details

Construction Type*

Exterior Finish

Roof Type

Roof Age (years)

Foundation

Garage

Systems & Updates

Heating Type

Cooling Type

Enter year of last update for each system (leave blank if unknown):

Electrical Year

Plumbing Year

HVAC Year

Roof Year

Water Heater Type

Wiring Type

Safety & Protective Devices

Deadbolt LocksSmoke DetectorsFire Alarm (Monitored)Burglar Alarm (Monitored)Burglar Alarm (Local)Fire ExtinguisherSprinkler SystemCarbon Monoxide DetectorStorm ShuttersImpact-Resistant WindowsGated CommunitySecurity CamerasSmart Home SecurityNone

Additional Structures & Liability Exposures

Swimming Pool on premisesTrampoline on premisesDog(s) on premisesWood stove / fireplaceHome-based business

Other Structures (fences, sheds, pools, etc.)

Current Insurance

Currently insured

Coverage Preferences

Desired Dwelling Coverage (Coverage A)

Personal Property (Coverage C)

Liability Limit (Coverage E)

Medical Payments (Coverage F)

Deductible Preference

Wind/Hail Deductible

Flood Insurance NeededReplacement Cost Contents

Desired Effective Date*

Mortgagee Information

Property has a mortgage / lienholder

Additional Notes

Referral Source

Additional Notes