- Capitol Benefits LLC

New Prospect Information Form

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone Number
Name
(If more than one name is listed on the Mortgage )
First Last
Date of Birth
MM slash DD slash YYYY
Current Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
New Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Does/Will the home have a central fire/burglar alarm:
Profession(s):
There are some discounts associated with certain professions
Do you currently have a renters or homeowners insurance policy? If so, what company is it with and how long have you been with them?
Do you have a dog? If so, what kind?
Do you have an Appraisal?
Closing Date
MM slash DD slash YYYY
Purchase Price:
If this is a new purchase.
Loan Amount:
If this is a new purchase.
Mortgagee Clause:
We can also get this information from your lender if you do not have it.
Please provide the approximate year the following were updated:
Roof:
Electrical:
Plumbing:
HVAC:
Will you be combining home/auto insurance?
(Combining your home and auto insurance will qualify you for a multi-policy discounts).
- Yes
- No
If you selected "Yes" to the question above please complete the questions below.
Drivers License Numbers and Dates of Birth:
Please provide this information for all licensed drivers in the household.
Vehicle Information
Please list the VIN number for each vehicle. If you don't have this available, please list the year, make, and model.
This is not required, but if readily available, please upload your most current insurance policy coverage declarations pages in PDF format so we can see the exact coverage limits you'd like us to compare. These can be easily downloaded from your online profile with your current provider (if you have a login), or from your current agent.
Max. file size: 98 MB.
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New Prospect Information Form

Please provide the approximate year the following were updated:

If you selected "Yes" to the question above please complete the questions below.

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We serve: CA, MN, IA, IN, OH, GA, PA, DE, MD, DC, NJ, CT, WV, IL,VA & NC

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New Prospect Information Form

Please provide the approximate year the following were updated:

If you selected "Yes" to the question above please complete the questions below.

Like Us

Connect With Us

We serve: CA, MN, IA, IN, OH, GA, PA, DE, MD, DC, NJ, CT, WV, IL,VA & NC

Join our Email List