Name: Riddick Insurance Group Inc.
Address: 5510 Six Forks Rd, Raleigh, NC, 27609, US
Telephone: (919) 870-1910

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Name
First Last
Referred By Client or Ref Partner
Address
Street Address Address Line 2 City State ZIP Code
Prior address if new purchase
Street Address Address Line 2 City State ZIP Code
Email
Email Spouse
Phone
Phone Spouse
Applicant Birthdate
MM slash DD slash YYYY
Co-applicant Birthdate
MM slash DD slash YYYY
We use a number of great partner carriers and I’d like to start by asking you some core underwriting questions that will help me immediately hone in on or eliminate some options for us.
What is the age of the roof of your home?
Have you had any home claims in the past 5-yrs? If so, what and when?
Do you have any dogs? If so what breed?
Have you or any insured driver in your home had any accidents or major moving violations (DUI) in the past 5-yrs?
What other agents/carriers have you contacted for quotes? I don’t want to potentially replicate something you’ve already seen OR help ensure I can highlight important differences for you.
Are you aware of any pre-existing conditions with your home’s mechanical systems, including your roof that will be unrepaired prior to closing
- Yes
- No
Trees overhanging or touching the home?
- Yes
- No
Age of Roof
Age of Roof
HVAC
Elec
Water Htr
Type of home (single family/townhome/condo)
Purchase price
Year Built
County
SQ Ft
Bathrooms
Fireplaces
Woodstove
- Yes
- No
Pool
- Yes
- No
Trampoline
- Yes
- No
Dogs
- Yes
- No
# of Dogs / Type
Flooring
- Carpet
- Hardwood
- Tile
- Vinyl
- Laminate
Garage
- 1 car
- 2 car
- 3 car
- Attached
- Detached
Outbuildings (are outbuildings metered separately or rented to others?)
Exterior Finish
Foundation
Alarm System
- Yes
- No
Do any household residents smoke?
- Yes
- No
Are you a AAA member?
- Yes
- No
Mem#
Employer Name/Title
Employer nm spouse
Do any named insureds have a college degree/graduate/vocational?
Is there any business usage or operations out of the home?
I want to make sure we present underwriting exposures correctly to carriers as well as apply the correct discounts you could be eligible for. Do you own any second homes, rental properties, boats, drones, or recreational vehicles (ATV’s/RV’s) ?
Do you have any Jewelry, artwork, or collectibles that you’d like coverage riders for?
Who is your current HOI with?
Notes
Auto
Vehicle
Make/Model Use/Yrly Miles VIN Comp/Coll BIPD
Insured with
Insured with
Limits
How do they pay / how much
Any tickets / accidents / claims in last 5 years
Are any vehicles used for uber/lyft/delivery?
If you have inexperienced operators, are any good students?
- Yes
- No
Are all vehicles titled in the name of the insured?
Does insured own any vehicles not garaged at this location?
Renewal Date
MM slash DD slash YYYY
May I quote any of boats, motorcycles, or campers/travel trailers if uncovered above?
- Yes
- No
Life
Who do you have life insurance with outside of work?
How much/term length/cost?
IF at work only, what is the benefit amount?
We include a simplified issue no-needle stick coverage sample (if client is under 40) for all of our clients, because it makes a major impact on their discounts and is critical for family protection. I’d like to ask you 3-4 quick questions so we can include that sample:
Height
Weight
Do you smoke?
What medications do you
Do you have any health conditions of any kind?
Notes
Agent
Phone
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Make/Model	Use/Yrly Miles	VIN	Comp/Coll	BIPD

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