Rudolf Insurance - Personal Lines Intake

Personal Lines Intake Questionnaire

Please fill this out to the best of your ability so we can get your quote started

Personal Info - Policyholder

Marital Status *

Married

Single

Divorced/Widowed

Date of birth *

Are you a military veteran?

Yes

No

Home Info

Address *

Country

How long have you lived at this location? *

Input approximate number of years as a whole number or decimal (e.g. 3, 5.5, 4.25)

Do you have a wood stove? *

Yes

No

Is the wood stove UL approved?

Yes

No

Unsure

Was the Woodstove professionally installed?

Yes

No

Unsure

How often do you have the wood stove, flue, and chimney cleaned?

Do you have a pool? *

Yes

No

Is your pool above or below ground?

Above

Below

Is there a slide or diving board for the pool?

Slide

Diving Board

Both

Neither

Is there a fence and secured gate to the pool to keep outsiders out?

Yes

No

Do you have a trampoline? *

Yes

No

Is your trampoline secured to the ground?

Yes

No

Do you have the safety netting around the circumference of the trampoline?

Yes

No

Is there a fence and secured gate to the trampoline to keep outsiders out?

Yes

No

Do you have a sump pump in the basement? *

Yes

No

N/A (no basement)

Any warning or Alarm system on the sump pump(s) when it fails?

Yes

No

Sump Pump Battery Backup?

Yes

No

Number of sump pumps

Automotive Info

Number of Drivers

The primary policyholder plus additional household drivers

Additional Drivers 4+ Info

Comma-separated list, one additional driver per line

Vehicles

One vehicle per line *VIN not needed if included in the policy docs uploaded below

Other Info

List types of pets, breed, and if there are histories of biting incidents

One line per pet

Do you have any high value property?

Please include details and estimated price for each, examples include: jewelry, guns, sporting equipment, etc.

Policy & Claims Info

Do we have permission to pull your credit report? *

Yes

A credit pull is required to apply for insurance

Will anyone else be designated as a named insured on the insurance policy? *

Yes

No

Do you have any home or auto claims in the past 5 years?

Yes

No

Home and Auto Claims and Dates

Do you have any auto violations in the past 5 years?

Yes

No

Upload current policy documents

This way we can provide a side by side comparison with equal limits and comparable premiums

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