Keystone Internal Long Form - Bear River Insurance

Internal Long Form

"*" indicates required fields

Let's Get To Know You!

Name Insured (You)*

First Last

Email*

Phone*

DOB*

mm/dd/yyyy

Gender*

Marital Status*

Occupation*

Employment/Position*

Company/School Name*

Home Address*

Street Address City State ZIP Code

Spouse/Significant Other Name*

First Last

Gender*

Spouse/Significant Other DOB*

mm/dd/yyyy

Spouse/Significant Other Phone Number*

Spouse/Significant Other Email*

Spouse/Significant Other Employment Stauts*

Spouse/Significant Other Occupation*

Spouse/Significant Other Company/School Name*

Policies

Select all that Apply*

Policy Start Date*

mm/dd/yyyy

How Did You Find Us?*

Who Should We Thank For Referring You?*

Home Details

Is This a New Construction?*

Yes

Estimated Completion Date*

mm/dd/yyyy

Property Usage*

Property Type*

Home Address (To Be Insured)*

Street Address City State ZIP Code

Year Built*

Square Feet*

Garage*

Number of Stories*

Age of Roof (Years)*

Roof Type*

Exterior Construction*

Number of Fireplaces*

Bathrooms*

Pool/Hot Tub*

Is it in a Fenced Yard?*

Yes

Does the Pool Have a Slide*

Yes

Does the Pool Have a Diving Board*

Yes

Trampoline*

Yes

Is there a 6 FT Fence Around the Yard?*

Yes

Is There a Basement?*

Yes

% of Basement Finished?*

Dogs?*

Yes

Dog Breed*

Additional Homes Details

Additional Homes

Home Address (To Be Insured)	Actions

There are no Entries.

Condo/Townhome Details

Condo or Townhome?*

Does the HOA Have a Master Policy?*

Yes

I Don't Know

Condo/Townhome Address*

Street Address City State ZIP Code

Year Built*

Garage*

Bathrooms*

Number of Stories*

Number of Fireplaces*

Age of Roof (Years)*

Trampoline*

Yes

Is there a 6 FT Fence Around the Yard?*

Yes

Pool/Hot Tub*

It it in a Fenced Yard?*

Yes

Does the Pool Have a Slide?*

Yes

Does the Pool Have a Diving Board?*

Yes

Discount Questions (Select All That Apply)*

Have You Had Any Prior Claims in the Last 5 Years?*

Yes

Prior Claim Details*

Dogs*

Yes

Breed of Dog(s)*

Renter Details

Property Type*

Square Feet*

Renter's Address*

Street Address City State ZIP Code

Trampoline*

Yes

Is there a 6 FT Fence Around the Yard?*

Yes

Pool/Hot Tub*

Is It In a Fenced Yard?*

Yes

Does the Pool Have a Slide?*

Yes

Does the Pool Have a Diving Board?*

Yes

Dogs*

Yes

Breed(s)*

Discount Questions (Click All That Apply)*

Fire Sprinklers

Gated Community

Monitored Alarm

None

Investment Property Details

Add Properties

Investment Address	Actions

There are no Entries.

Auto Details

Current Auto Insurance Company*

Add Drivers

Driver Name	Actions

There are no Entries.

Add Vehicles

Vehicle Details	Actions

There are no Entries.

Umbrella Details

Number of Residences You Occupy*

Number of Rental Units You Own*

Number of Drivers*

Any Driver Under 25?*

Yes

Number of Cars You Own*

Any Boats, RVs, Motorcycles, Or Other Vehicles You Own?*

Yes

Life Insurance

Desired Amount*

Term Length*

Height*

Weight*

Current Life Insurance*

Yes

Current Life Insurance Amount*

Current Life Insurance Company*

Do You or Have You Ever Used Tobacco?*

Yes

Quantity*

(I.E. One Pack or Half a Pack)

Frequency*

(I.E. Per Day or Per Week)

Form*

(I.E. Cigarettes, Chew, Vape)

Last Used*

(I.E. A Year Ago, A Month Ago, Yesterday)

Have You Used Marijuana in the Last 5 Years (Don't Worry, You Are Still Insurable)*

Yes

Have You Seen a Doctor in the Last 5 Years?*

(This excludes Regular Checkups, Colds, Flus, Etc)

Yes

Please Indicate The Approximate Date and the Reason For the Visit*

Are You Taking Any Prescription Medication?*

Yes

Please List All Currently Prescribed Medication Outside of a Common Prescribed Antibiotic in the Last 5 Years

Medication Name	Actions

There are no Entries.

Have Any Immediate Family Members (Parents and/or Siblings) Passed Away Prior to the Age of 60 Due to Cancer, Diabetes, or Cardiovascular Diseases?*

Yes

Any Moving Violations Including but Not Limited to Driving Under the Influence (DUI) in the Last 5 Years*

Yes

Please Provide Details*

Any Private Pilot Activity in the Last 3 Years or Planned for the Future*

Yes

Any Past Travel in the Last 2 Years or Future Plans in the Next 2 Years to Travel Outside of the U.S.*

Yes

Please Provide Details Including Specific Destination, Frequency, and Duration of Travel*

Are You a Citizen or Legal Resident of the U.S.?*

Yes

Would You like to Create a Policy for Others?*

Yes

Create an Additional Policy for an Applicant

Applicant's Name	Actions

There are no Entries.

Boat/Trailer Details

Do You Want to Insure a Boat or Trailer?*

Boating Accident/Violation in the Last 5 Years*

Yes

Details of Accident(s) and/or Violation(s)*

Years of Boating Experience*

Have You Completed a Safety Course*

Yes

Boat Purchased New or Used?*

New

Used

Date Purchased*

mm/dd/yyyy

Boat Value*

Boat Year*

Boat Make*

Boat Model*

Boat Length*

Propulsion Type*

Horse Power*

Maximum Speed*

Hull ID*

Construction Material*

Boat Stored at Home Address*

Yes

Leased/Rented to Others*

Yes

Boat Storage Location*

Street Address City State ZIP Code

Used for Business*

Yes

Previously Salvaged*

Yes

Permanent Living Quarters*

Yes

High Performance (Fast)*

Yes

Number of Motors*

Exposed Engine, Other than Outboard*

Yes

Corporate Owned*

Yes

Name of Owner*

Do You Have a Lienholder*

Yes

Lienholder*

Any Additional Equipment

What Trailer(s) Do You Want to Insure

Trailer Make	Actions

There are no Entries.

ATV/Golf Cart Details

Current ATV/Golf Cart Insurance Company*

Driver Details

Name	Actions

There are no Entries.

Other Vehicle Details

Vehicle Type	Actions

There are no Entries.

Motor Home/Travel Trailer Details

Motor Home or Travel Trailer*

Motor Home

Travel Trailer

Year*

Make*

Model*

Length (in ft)*

Year Purchased*

Estimated Value Today*

Vin #*

How Many Days Per Year is it Used*

Motor Home Rented Commercially or Used for Business Purposes*

Yes

Motor Home Rented to Others*

Yes

Motor Home Taken to and From Work or Used at a Work Location*

Yes

Primary Vehicle Use*

Stored at Home*

Yes

Motor Home Storage Address*

Street Address City State ZIP Code

Motorcycle/Dirt Bike Details

Current Motorcycle Insurance Company*

Rider Details

Name	Actions

There are no Entries.

Motorcycle/Dirt Bike Details

Make	Actions

There are no Entries.

Comments

This field is for validation purposes and should be left unchanged.