Quick Insurance Questionnaire - Captrust - McMichael Insurance Agency

Please take a moment to answer each question on this survey so we can better evaluate your insurance needs. Once completed, we can match you with the right program from among 30 different "A" rated insurance companies to get you the right coverage at the right price.

Step 1 of 2

What services does Captrust provide for you?(Required)

Who is your Wealth Management Advisor?

Name(Required)

First Last

Email Address(Required)

Your Cell Phone Number(Required)

Residential Address(Required)

Street Address Address Line 2 City State ZIP Code

Marital Status(Required)

Please indicate your spouse or partner's name:(Required)

First Last

Significant savings are available by bundling your auto and home insurance together. What would you like us to quote for you today?(Required)

Auto & Home

Auto Only

Home Only

AUTO INSURANCE QUESTIONS

What is your highest level of education? (Discounts may apply)(Required)

What is your spouse/partner's highest level of education? (Discounts may apply)(Required)

What is your occupation? (Discounts may apply)(Required)

What is your spouse/partner's occupation? (Discounts may apply)(Required)

How many drivers live in your household? Please include yourself. (Without the use of Canopy Connect's integration, we need to collect all driver information in order to get you an accurate quote.)(Required)

Driver 1 Name(Required)

First Last

Driver 1 Driver's License #:(Required)

Driver 1 License State:(Required)

State

Driver 1 Social Security #:

Driver 1 D.O.B.(Required)

Driver 2 Name(Required)

First Last

Driver 2 Driver's License #:(Required)

Driver 2 License State:(Required)

State

Driver 2 Social Security #:

Driver 2 D.O.B.(Required)

Driver 3 Name(Required)

First Last

Driver 3 Driver's License #:(Required)

Driver 3 License State:(Required)

State

Driver 3 Social Security #:

Driver 3 D.O.B.(Required)

Driver 4 Name(Required)

First Last

Driver 4 Driver's License #:(Required)

Driver 4 License State:(Required)

State

Driver 4 Social Security #:

Driver 4 D.O.B.(Required)

Driver 5 Name(Required)

First Last

Driver 5 Driver's License #:(Required)

Driver 5 License State:(Required)

State

Driver 5 Social Security #:

Driver 5 D.O.B.(Required)

If you have more drivers in your household than the ones listed, please record their name, drivers license number and state, social security number and dates of birth here:

Have you or any driver had any violations and/or accidents in the past 3 years?(Required)

Please explain when and what violations and/or accidents have occurred in the past 3 years?(Required)

For violations please give information regarding the circumstances of the violation (i.e. speeding ticket, ran a stop sign, etc.) For accident information, please include whether you were at-fault or not at-fault.

Would you be willing to install usage-based monitoring devices? (Discounts may apply)(Required)

How would you like to pay your auto policy premium? (Discounts may apply)(Required)

Do you have any students in the household that have a GPA of 3.0 or higher? (Discounts may Apply)(Required)

*If applicable, the insurance carrier may require proof in the form of a report card to be submitted before discounts would be given.

Please list the names of the students that have a GPA of 3.0 or higher:(Required)

Do any residents temporarily live elsewhere?(Required)

Do any of your household drivers have access to drive autos not insured on your policy?(Required)

This includes other household vehicles not insured on your policy, as well as employer-provided vehicles.

Are all household drivers currently listed on your Auto policy?(Required)

Note: Unreported drivers may not be covered. Accurate policy information is critical.

Any business use?(Required)

Business Use

Sales Calls Contracting Delivery Ride Sharing (Uber/Lyft) Renting your vehicle to others (Turo)

Business Use %

Do you use your vehicle for any rideshare or delivery services including but not limited to Uber, Lyft, DoorDash, etc.?(Required)

These factors could have extra exposure and coverage concerns that we would want to advise you on to ensure you are properly covered. Your carrier could deny a claim if you do not disclose rideshare or delivery use of your vehicle(s).

Are any vehicles titled to a business (Corp, LLC, Partnership)?(Required)

Please describe which car(s) you use for this service:(Required)

Please describe which vehicles are titled to a business:(Required)

Please explain why there are household drivers that you do not wish to be listed on your Auto policy.(Required)

Please list household members you do not want to be included as a driver on your policy. Explain why you do not want to include them (i.e. Name - they are only 12 years old; Name - they have their own car [year, make, model] and insurance through [insurance carrier]; Name - they have a suspended license and I do not want to include them on my policy.)

Do you have any modifications on any of your vehicles?(Required)

Insurance only covers the original type of parts associated with your VIN. If you added a wrap, specialized rims & tires, custom stereo, lift kit, etc. (these items may not be covered on your current policy).

Please explain which vehicles are customized and provide the description and value of the modifications.(Required)

Please check all the coverages you would like to consider adding to your new Auto insurance.(Required)

None

Full Glass (No deductible applies)

New or Better Car Replacement

Lease/Loan Gap

Vacation Emergency Expense

Original Manufacturer New Parts

Rental Reimbursement

Towing/Roadside Assistance

Customizing Equipment

HOME INSURANCE QUESTIONS

Is the home you want quoted your current home or is it a new home?(Required)

Please provide the address of your new home:(Required)

Street Address Address Line 2 City State ZIP Code

How is the home deeded?(Required)

Do you occupy any other locations on a long-term basis?(Required)

For example, campsites, rental apartments, and remote workers who may reside for extended periods of time away from your primary residence.

Please explain the other type of deed:(Required)

Do you ever rent out your home or any rooms within your home?(Required)

Yes

Any business conducted from home?(Required)

Yes

Please Explain:

What year was your home built?(Required)