BindFlow — Insurance Intake Platform

Let's get started

Tell us what you need covered and how you're submitting this request.

Policy Type

🏠

Homeowners

HO-3

🏢

Renters

HO-4

🚧

Vacant

DP-1

🔑

Rental Owner

DP-3

🏙️

Condo

HO-6

🚗

Vehicle

Personal / Commercial

🏢

Business Insurance

Commercial Lines / ACORD

❤️

Life & Health

Health · Medicare · Life

🏗️

Builder's Risk

New Construction · Renovation

🏥

Health Insurance

Under 65

💊

Medicare

65 & Over

🛡️

Life Insurance

Term · Whole · Final Expense

🚗

Personal Vehicle

Personal

🚛

Commercial Auto

CAP

ℹ️ Select the coverage types your business needs — most businesses need more than one. Not sure what you need? Select everything that sounds relevant and your agent will guide you. Your business information (entered once) will auto-fill across all selected forms.

🛡️

General Liability

Slip & fall · Property damage · Lawsuits

👷

Workers Compensation

Employee injuries on the job

☂️

Excess / Umbrella

Extra coverage above your other policies

🏪

Business Owners Policy

Building · Contents · Liability in one

🚛

Commercial Auto

Business vehicles · Trucks · Fleets

🏗️

Commercial Property

Buildings · Equipment · Business contents

🔒

Crime / Fidelity

Employee theft · Fraud · Forgery

⚖️

Employment Practices

Harassment · Discrimination · Wrongful termination

Selected forms: None selected

Submission Type

👤

I'm the Homeowner / Renter

🏡

I'm a Realtor

🏦

I'm a Lender

Effective Date

Desired Effective Date *

Applicant Information

Tell us about the person or entity being insured.

Insured Entity Type

Primary Applicant

First Name *

Last Name *

Date of Birth *

Marital Status

Email *

Phone *

Current Address

Street Address

City

State

ZIP Code

How long at this address?

Mailing Address (where policy documents and bills should be sent)

Same as Current Address Same as Property Being Insured Different Address

Mailing Street Address

City

State

ZIP Code

Prior Insurance

Prior Carrier

Prior Policy Expiration

Years Continuously Insured

📄

Have a Current Insurance Declarations Page?

Upload your current policy's dec page — we'll fill in your prior carrier, expiration date, and current coverage details automatically

⚡ Reading declarations page...

✓ Auto-filled from your declarations page

Review the fields below and correct anything that doesn't look right.

Loss History (Last 5 Years)

Any losses in the last 5 years?

No losses Yes, I have losses

Date	Type of Loss	Amount Paid	Description

Co-Applicant

First Name

Last Name

Date of Birth

Relationship to Primary

Email

Phone

Same address as primary?

Yes No — different address

Co-Applicant Losses Last 5 Years?

Entity Information

Entity Name *

Entity-Specific Detail

Type of Trust *

Some carriers restrict coverage for certain trust types (e.g. land trusts, irrevocable trusts) — the assigned agent will confirm eligibility.

Authorized Representative Name

Title / Role

Representative DOB

Representative Email

Representative Phone

Entity Mailing Address

Street Address

City

State

ZIP

Loss History (Last 5 Years)

Any losses in the last 5 years?

No losses Yes

Date	Type of Loss	Amount Paid	Description

Property Information

Enter the property address and we'll look up the record automatically.

Property Address Being Insured

Street Address *

City *

State

ZIP Code *

Documents (Optional — auto-fills property & coverage details)

🏷️

MLS Sheet

Upload listing PDF — extracts year built, sq ft, construction & more

⚡ Reading MLS sheet...

🗂️

Property Record Card

Upload county appraiser record — extracts year built, sq ft, construction, roof & more

⚡ Reading property record card...

📋

4-Point Inspection

Upload PDF — we'll extract roof, electrical, plumbing & HVAC details automatically

⚡ Reading inspection document...

🌀

Wind Mitigation Report

Upload PDF — we'll extract roof shape, deck attachment & opening protection

⚡ Reading wind mitigation report...

✓ Auto-filled from inspection document

Review the fields below and correct anything that doesn't look right.

Rental Property Details

Landlord / Property Management Name

Landlord Phone

Estimated Personal Property Value

Additional Insured Needed?

Property Basics

Is this a purchase or existing home?

Year Built

Living Area (sq ft) *

Construction Type

Number of Stories

Foundation Type

Occupancy Type

Garage Type

Garage Size

Number of Fireplaces

Gated Community?

Business Conducted on Premises?

Short-Term Rental (Airbnb/VRBO)?

Condo Details

Condo Association Name

Unit Number

Floor Number

Building Name

Master Policy Deductible (HOA carries)

Loss Assessment Coverage Needed?

Vacant Property Details

Reason for Vacancy

How Long Vacant?

Is Property Secured?

Ongoing Renovations?

Expected Occupancy Date

Rental Owner Details

Owner Occupying Any Portion?

Number of Rental Units

Currently Tenanted?

Monthly Rental Income

Tenant Screening in Place?

Roof

Roof Material

Roof Shape

Original to Home?

Year Replaced

Full or Partial Replacement?

Permit Pulled for Replacement?

Wind Mitigation Inspection on File?

Electrical

Electrical System Original to Home?

Year Updated

Full or Partial Update?

Panel Brand

Amperage

Knob & Tube Wiring Present?

Aluminum Wiring Present?

Plumbing

Plumbing Original to Home?

Year Updated

Full or Partial Update?

Pipe Material (select all that apply)

Copper CPVC PVC PEX Galvanized Steel ⚠️ Polybutylene ⚠️ Cast Iron Lead ⚠️ Unknown

Water Heater Year

Water Heater Type

Whole-House Water Shutoff Present?

HVAC / Heating

HVAC Original to Home?

Year Updated

Full or Partial Replacement?

System Type

Heat Source

Number of Units

Last Service Date

Pool & Exterior

Pool on Property?

Pool Type

Pool Square Footage

Pool Age / Year Installed

Fenced / Gated?

Pool Alarm?

Diving Board?

Slide?

Screened Enclosure on Property?

Enclosure Square Footage

Year Installed

Does the Enclosure Surround the Pool?

Solar Panels on Property?

Total System Value

Owned or Leased?

Mounting Type

Dogs on Property?

Trampoline?

Breed

Weight (lbs)

Central Alarm System?

Monitoring Company

Centrally Monitored?

Sinkhole Activity

Any known sinkhole activity on or near the property?

No known activity Yes

Status

Year Repaired

Repair Method

Engineer Certified Repair?

Documentation Available?

Prior Sinkhole Insurance Claim?

Year of Claim + Carrier

Ground Subsidence / Settling Visible?

🚨Unrepaired sinkhole activity significantly limits carrier options. The assigned agent will advise on available markets.

Coverage Preferences

Review the suggested amounts below. All values can be adjusted.

Dwelling Coverage ?

Covers the cost to rebuild or repair the physical structure of your home — walls, roof, floors, built-in appliances — if damaged by a covered event like fire, wind, or a fallen tree.

⚡ Dwelling Calculator

Living Area (sq ft)

Auto-filled from property info if entered

Suggested Dwelling Amount

$0 at $250/sq ft

Dwelling Coverage Amount *

Adjust as needed — calculator is a starting point

Other Structures ?

Covers structures on your property that are not attached to your home — detached garages, fences, sheds, guest houses, or pool enclosures. Set as a percentage of your dwelling coverage.

Coverage Percentage of Dwelling

$0

Personal Property ?

Covers your belongings — furniture, clothing, electronics, appliances — if they are stolen or damaged. RCV pays to replace items at today's prices. ACV pays what your used item is worth today after depreciation.

Coverage Percentage of Dwelling

$0

Valuation Method

Replacement Cost Value (RCV)
We pay what it costs to buy it brand new today Actual Cash Value (ACV)
We pay what it's worth today after age and wear

Deductibles ?

The amount you pay out of pocket before insurance kicks in. Florida policies often have three separate deductibles: one for everyday losses (All Other Perils), one for wind damage, and one specifically for hurricanes — which is usually a percentage of your dwelling value.

All Other Perils

Wind Deductible

Hurricane Deductible

Liability & Additional Coverages

Liability Limit ?

Protects you if someone is injured on your property or you accidentally damage someone else's property. Covers legal fees and settlements. For example, if a guest slips and falls and sues you, this pays for your legal defense and any judgment against you.

Medical Payments Limit ?

Pays for minor medical bills if someone is injured on your property — regardless of fault. Think of it as a goodwill coverage that handles small injuries quickly without a lawsuit. Covers things like a neighbor's ER visit after tripping on your steps.

Ordinance or Law Coverage

Covers cost to bring structure up to current building codes after a covered loss

Loss of Use / Additional Living Expenses

Flood Coverage

Umbrella Policy Needed?

Jewelry / Valuables Scheduling?

Renters Coverage

Personal Property Coverage

Liability Limit

Deductible

Flood Coverage Needed?

Referral & Transaction Info

Provide your contact info and transaction details for the agency.

How Did You Hear About Us?

Realtor Information

Your Name *

Company / Brokerage

Phone *

Email *

Transaction Details

Purchase Price

Closing Date *

Loan Type

Loan Amount

Lender / Mortgagee Clause

Lender Name

Lender Contact Email

Lender Address (for mortgagee clause)

Loan Number

📨

Send Your Buyer a Pre-Filled Link

Enter your buyer's email below and we'll send them a personalized link to complete the remaining details — loss history, coverage preferences, and anything else only they would know. Their form will be pre-filled with everything you've already entered.

Buyer First Name

Buyer Last Name

Buyer Email *

Buyer Phone

Lender Information

Your Name *

Company / Institution

Phone *

Email *

Loan Details

Purchase Price

Loan Amount

Loan Type

Required Closing Date *

Loan Number

Minimum Dwelling Coverage Required

Mortgagee Clause

Lender Legal Name (for mortgagee clause)

Lender Address

Contact for Evidence of Insurance

Contact Email

📨

Send Your Borrower a Pre-Filled Link

Enter your borrower's email and we'll send them a personalized link to complete the remaining details. Their form will be pre-filled with the property address, loan info, and closing date you've already entered.

Borrower First Name

Borrower Last Name

Borrower Email *

Borrower Phone

Additional Insureds & Interested Parties

Add any lenders, HOAs, co-owners, trustees, or other parties that need to be listed on the policy.

Additional Notes

Anything else the agency should know before quoting?

Additional Notes / Special Circumstances

Review Your Submission

Please review the information below before submitting. A licensed agent will reach out to present quotes.

ℹ️ By submitting this form you authorize a licensed insurance agent to contact you regarding coverage options. No coverage is bound until you receive a policy from a licensed carrier.

Driver Information

Tell us about everyone who will be operating the vehicle(s).

Primary Driver

First Name *

Last Name *

Date of Birth *

Gender

Marital Status

Email *

Phone *

License Information

Driver's License Number

State Issued

License Status

Years Licensed

SR-22 Required?

Current Address

Street Address

City

State

ZIP Code

Prior Insurance

Current / Prior Carrier

Policy Expiration Date

Years Continuously Insured

Reason for Shopping

📄

Upload Current / Prior Declarations Page

PDF or image — we'll extract carrier, limits, deductibles & expiration date automatically — prior auto policy

⚡ Reading declarations page...

Violations & Claims (Last 5 Years)

Any violations, accidents, or claims in the last 5 years?

None Yes

Date	Type	At Fault?	Description

Additional Drivers

Vehicle Information

Tell us about the vehicle(s) being insured — cars, trucks, motorcycles, boats, RVs, off-road vehicles, and more.

Coverage Preferences

Florida requires PIP and Property Damage Liability. All other coverages are optional but recommended.

Liability Coverage ?

Pays for injuries and property damage you cause to others in an accident. Florida requires a minimum of $10,000 per person / $20,000 per accident for bodily injury. Higher limits protect your personal assets if you're sued.

Bodily Injury Liability

Property Damage Liability

PIP — Personal Injury Protection ?

Required in Florida. Pays for your own medical expenses and lost wages after an accident — regardless of who was at fault. Florida's no-fault law requires a minimum of $10,000 PIP coverage.

PIP Limit

PIP Deductible

Work Loss Exclusion?

Uninsured / Underinsured Motorist ?

Protects you if you're hit by a driver who has no insurance or not enough insurance to cover your injuries. Florida has a high rate of uninsured drivers — this coverage is strongly recommended.

UM / UIM Coverage

UM Type

Comprehensive & Collision

Comprehensive Deductible ?

Covers damage to your vehicle from non-collision events — theft, vandalism, weather, hitting an animal. The deductible is what you pay before insurance covers the rest.

Collision Deductible ?

Covers damage to your vehicle when you collide with another car or object. Required by most lenders if your vehicle is financed or leased.

Additional Coverages

Medical Payments

Rental Reimbursement?

Roadside Assistance?

Gap Coverage?

Covers the difference between what you owe and what your vehicle is worth if it's totaled

Final Details

Almost done — just a few more details before we submit.

Dealer Information

Salesperson / Contact Name *

Dealership Name

Phone *

Email *

Sale Details

Sale Price of Vehicle

Amount Financed

Lender / Finance Company

Lender Address (for lienholder clause)

📨

Send Your Buyer a Pre-Filled Link

Enter your buyer's contact info and we'll send them a link to complete any remaining details. Their form will be pre-filled with the vehicle and financing info you've already entered.

Buyer First Name

Buyer Last Name

Buyer Email *

Buyer Phone

Additional Notes

Review & Submit

ℹ️ By submitting this form you authorize a licensed insurance agent to contact you regarding coverage options. No coverage is bound until you receive a policy from a licensed carrier.

Business Information

Tell us about the business being insured.

Business Profile

Business Legal Name *

DBA / Trade Name (if different)

Entity Type

FEIN / Tax ID

Years in Business

Years with Prior Carrier

Business Contact

Primary Contact Name *

Title / Role

Business Phone *

Business Email *

Business Address

Street Address *

City

State

ZIP Code

Business Operations

Nature of Business / Industry *

DOT Number (if applicable)

MC Number (if applicable)

Any prior cancellations or non-renewals?

Reason for Cancellation / Non-Renewal

Prior Carrier

Prior Policy Expiration

📄

Upload Current / Prior Declarations Page

PDF or image — we'll extract carrier, limits, deductibles & expiration date automatically — prior commercial auto policy

⚡ Reading declarations page...

Driver Information

List all drivers who will operate the commercial vehicles. Carriers will pull MVRs on all listed drivers.

ℹ️ By submitting this form you authorize the agent to obtain Motor Vehicle Records (MVRs) for all listed drivers as part of the underwriting process.

Vehicle Schedule

List all vehicles to be covered under the commercial auto policy.

Coverage Preferences

Select the coverage limits for your commercial auto policy.

Liability Coverage ?

Commercial auto liability covers injuries and property damage you or your employees cause while operating covered vehicles on business. Higher limits are required for vehicles over 10,001 lbs GVW or vehicles carrying goods for hire.

Combined Single Limit (CSL) or Split Limit

CSL Limit

Bodily Injury

Property Damage

Physical Damage

Comprehensive Deductible

Collision Deductible

Additional Coverages

Uninsured / Underinsured Motorist

Medical Payments

Hired Auto Liability?

Covers vehicles you rent or hire for business use

Non-Owned Auto Liability?

Covers employees using their personal vehicles for business

Motor Truck Cargo?

Cargo Limit

Primary Commodity / Cargo Type

Trailer Interchange?

Covers non-owned trailers in your care, custody, or control

Gap Coverage?

Additional Insured Needed?

Additional Insured Name / Entity

Additional Notes & Review

Anything else the agent should know before quoting?

Additional Notes / Special Circumstances

Review Summary

ℹ️ By submitting this form you authorize a licensed commercial lines agent to contact you regarding coverage options. Motor Vehicle Records will be pulled on all listed drivers as part of the underwriting process. No coverage is bound until you receive a policy from a licensed carrier.

Master Applicant Profile

Enter your business information once — it will auto-fill (highlighted in green) across all selected commercial forms.

✅ Fields marked with a MAP badge throughout the forms are pre-filled from this profile. You can always override any auto-filled value.

Named Insured / Business

Named Insured (Legal Business Name) *

DBA / Trade Name

Entity Type

FEIN / Tax ID

SIC / NAICS Code

Years in Business

Website

Mailing Address

Street Address *

City *

State

ZIP Code

County

Primary Contact

Contact Name *

Title / Role

Phone *

Email *

Prior Insurance

Current / Prior Carrier

Policy Expiration Date

Years with Prior Carrier

Any Prior Cancellations or Non-Renewals?

Nature of Business

Describe Business Operations *

Number of Employees (Full Time)

Number of Employees (Part Time)

Annual Gross Revenues

Annual Payroll

Annual Subcontractor Cost

Do you have any subsidiaries?

Desired Effective Date

📄

Upload Your Current Declarations Pages

Upload a dec page for each line of commercial insurance you currently carry — GL, WC, Auto, Property, Umbrella, etc. Upload them one at a time. Each one will be read and applied to the matching form automatically.

⚡ Reading declarations page...

Forms Selected

No forms selected yet.

General Liability ACORD 125/126

Commercial General Liability coverage for bodily injury, property damage, and personal/advertising injury.

Named Insured MAP

Named Insured

Mailing Address

FEIN

Entity Type

Contact Name

Phone

Effective Date

Expiration Date

📄

Upload Current / Prior Declarations Page

PDF or image — we'll extract carrier, limits, deductibles & expiration date automatically — prior GL policy

⚡ Reading declarations page...

Coverage Information — ACORD 126

Policy Type

Retroactive Date (Claims Made only)

General Aggregate Limit

Each Occurrence Limit

Products / Completed Operations Aggregate

Personal & Advertising Injury

Damage to Rented Premises

Medical Expense (Any One Person)

Deductible

Operations / Exposure

Description of Operations

Annual Gross Revenue

Annual Payroll

Subcontractor Costs

Square Footage of Operations

Do you have a certificate of insurance requirement?

Liquor Liability Exposure?

Professional Services Exposure?

Work performed underground?

Work performed on or near railroads?

Any prior GL losses last 5 years?

Loss Detail

Additional Interests

Additional Insured (name/entity if required by contract)

Waiver of Subrogation Required?

Primary / Non-Contributory Required?

Workers Compensation ACORD 130

Workers Compensation and Employers Liability coverage for work-related injuries and illnesses.

Named Insured MAP

Named Insured

Mailing Address

FEIN

Entity Type

Contact Name

Phone

Effective Date

Coverage — Part One (Workers Compensation)

State(s) of Operation *

Other States Coverage

Coverage — Part Two (Employers Liability)

Bodily Injury by Accident (Each Accident)

Bodily Injury by Disease (Policy Limit)

Bodily Injury by Disease (Each Employee)

Deductible

Payroll by Classification

State	Class Code	Description of Work	Full Time EE	Part Time EE	Annual Payroll

Experience Modification

Experience Modification Rate (EMR)

NCCI / State Rating Bureau

Prior Carrier

Prior Policy Expiration

📄

Upload Current / Prior Declarations Page

PDF or image — we'll extract carrier, limits, deductibles & expiration date automatically — prior WC policy

⚡ Reading declarations page...

Any WC losses last 3 years?

Loss Detail (date, type, amount)

Additional Info

Are any employees leased?

Do subcontractors carry their own WC?

Any employees work from home?

Any maritime / USL&H exposure?

Excess / Umbrella ACORD 131

Excess liability coverage over underlying GL, Auto, and WC policies.

Named Insured MAP

Named Insured

Address

FEIN

Effective Date

📄

Upload Current / Prior Declarations Page

PDF or image — we'll extract carrier, limits, deductibles & expiration date automatically — prior excess/umbrella policy

⚡ Reading declarations page...

Excess / Umbrella Coverage

Coverage Type

Occurrence Limit

Aggregate Limit

Self-Insured Retention (SIR)

Underlying Policies

GL Underlying Limit

GL Carrier

Auto Underlying Limit (CSL)

Auto Carrier

WC Employers Liability Limit

WC Carrier

Business Owners Policy ACORD 140

Combined property and liability coverage for small to mid-size businesses.

Named Insured MAP

Named Insured

Address

FEIN

Effective Date

Years in Business

Annual Revenue

📄

Upload Current / Prior Declarations Page

PDF or image — we'll extract carrier, limits, deductibles & expiration date automatically — prior BOP policy

⚡ Reading declarations page...

Location / Building

Location Address (if different from mailing)

Building Ownership

Building Construction

Year Built

Square Footage

Number of Stories

Sprinkler System?

Alarm System?

Property Coverage

Building Value

Business Personal Property (Contents)

Valuation

Business Income / Loss of Rents

Property Deductible

Equipment Breakdown?

Outdoor Signs Value

Money & Securities Limit

Liability Coverage

Each Occurrence

General Aggregate

Products / Completed Operations

Hired / Non-Owned Auto?

Employment Practices Liability?

Cyber Liability?

Commercial Auto ACORD 127

Commercial automobile liability and physical damage coverage per ACORD 127 standards.

Named Insured MAP

Named Insured

Address

FEIN

Effective Date

Prior Carrier

Prior Policy Expiration

📄

Upload Current / Prior Declarations Page

PDF or image — we'll extract carrier, limits, deductibles & expiration date automatically — prior commercial auto policy

⚡ Reading declarations page...

ℹ️ This form follows ACORD 127 standards. Vehicle schedule and driver information captured below mirrors the standalone Commercial Auto application.

Coverage Symbols (ACORD 127)

Liability Symbol

Physical Damage Symbol

Liability Limits

Liability Type

CSL Limit

Bodily Injury

Property Damage

UM / UIM

Medical Payments

Hired Auto Liability?

Non-Owned Auto Liability?

Physical Damage

Comprehensive Deductible

Collision Deductible

Motor Truck Cargo?

Cargo Limit

Trailer Interchange?

Gap Coverage?

Vehicle Schedule

Driver Schedule

Commercial Property ACORD 140

Standalone commercial property coverage for buildings and business personal property.

Named Insured MAP

Named Insured

Mailing Address

FEIN

Effective Date

📄

Upload Current / Prior Declarations Page

PDF or image — we'll extract carrier, limits, deductibles & expiration date automatically — prior commercial property policy

⚡ Reading declarations page...

Location & Building Details

Risk / Location Address

Building Ownership

Year Built

Construction Type

Total Square Footage

Number of Stories

Roof Type / Material

Roof Year

Sprinkler System

Burglar Alarm

Fire Alarm

Any renovations in last 3 years?

Coverage

Building Replacement Cost Value

Business Personal Property

Valuation Basis

Cause of Loss Form

All-Risk Deductible

Wind / Hail Deductible

Business Income / Extra Expense

Flood Coverage Needed?

Equipment Breakdown?

Ordinance or Law?

Crime / Fidelity ACORD 150

Coverage for employee dishonesty, theft, forgery, computer fraud, and other crime exposures.

Named Insured MAP

Named Insured

Address

FEIN

Effective Date

Number of Employees

Annual Revenue

📄

Upload Current / Prior Declarations Page

PDF or image — we'll extract carrier, limits, deductibles & expiration date automatically — prior crime/fidelity policy

⚡ Reading declarations page...

Coverage Requested

Employee Dishonesty / Fidelity

Forgery or Alteration

Theft, Disappearance & Destruction

Computer Fraud

Funds Transfer Fraud

Money Orders / Counterfeit

Policy Type

Deductible

Underwriting Questions

Do employees handle cash or checks?

Are background checks conducted?

Are accounts reconciled monthly?

Any prior crime losses?

Maximum cash on premises at any time

Maximum cash in transit at any time

Employment Practices Liability EPLI

Coverage for claims made by employees alleging discrimination, harassment, wrongful termination, and other employment-related offenses.

Named Insured MAP

Named Insured

Address

FEIN

Effective Date

Number of Full Time Employees

Number of Part Time Employees

Annual Revenue

Annual Payroll

📄

Upload Current / Prior Declarations Page

PDF or image — we'll extract carrier, limits, deductibles & expiration date automatically — prior EPLI policy

⚡ Reading declarations page...

Coverage

Limit of Liability

Retention / Deductible

Include Third Party Coverage?

Include Wage & Hour Defense?

Underwriting Questions

Does the company have an employee handbook?

Written anti-harassment / discrimination policy?

Formal complaint / grievance procedure?

Any employee terminations in last 12 months?

Number of terminations

Any pending or prior EPLI claims?

Claim detail (date, type, outcome)

Union employees?

Do you operate in California?

Additional Notes & Review

Final details before submitting your commercial lines application.

Additional Notes / Special Circumstances

Forms Submitted

Review Summary

ℹ️ By submitting this form you authorize a licensed commercial lines agent to contact you regarding coverage options. No coverage is bound until you receive a policy from a licensed carrier.

Health Insurance Under 65

Individual and family health insurance — private plans, off-exchange, ACA Marketplace, and short-term options.

Primary Applicant

First Name *

Last Name *

Date of Birth *

Gender

Email *

Phone *

County of Residence *

ZIP Code

Tobacco Use in Last 12 Months?

Height

Weight (lbs)

Desired Effective Date

Household Members to Be Covered

ℹ️ Add all family members who need coverage — spouse, children, or other dependents.

Current Coverage

Current Coverage Status

Current Carrier (if insured)

Current Plan Expiration / Loss of Coverage Date

Reason for Shopping

Coverage Preferences

Market Preference

Preferred Plan Type

Coverage Level Preference

Maximum Monthly Premium Budget

Dental Coverage Needed?

Vision Coverage Needed?

Household & Income Information (Optional — helps agent check all available options)

💡 This information helps your agent determine whether you qualify for ACA subsidies, private plan discounts, or Medicaid — and find the best value across all markets. It is completely optional and stays confidential.

Household Size (total people in home)

Estimated Annual Household Income

Is anyone in your household offered employer coverage?

Medical Information (Per Person — Optional but Helpful)

ℹ️ Carriers underwrite each person individually. Complete as much as you can — this helps your agent find the best plan and check network and formulary coverage for each member.

Preferred Doctors / Specialists (applies to all members)

🧑 Primary Applicant — Medical Profile

Current Medications

Ongoing Medical Conditions

Upcoming Surgeries or Procedures

Injuries or Illnesses in the Last 5 Years (that may appear on a medical report)

📄

Upload Current Health Insurance Declarations Page

PDF or image — we'll extract your current carrier, plan type, and coverage details automatically

Additional Notes

ℹ️ By submitting this form you authorize a licensed health insurance agent to contact you regarding coverage options. No coverage is bound until you receive a policy from a licensed carrier.

Medicare 65 & Over

Medicare Supplement (Medigap), Medicare Advantage (Part C), and Part D prescription drug plans.

Applicant Information

First Name *

Last Name *

Date of Birth *

Gender

Email *

Phone *

County of Residence *

ZIP Code

Medicare Beneficiary ID (MBI)

Tobacco Use in Last 12 Months?

Medicare Enrollment Status

Medicare Part A Effective Date

Medicare Part B Effective Date

Currently Enrolled in Medicare Advantage or Supplement?

Current Plan / Carrier Name

Reason for Shopping / Change

Desired Effective Date

Coverage Preference

Preferred Coverage Type

If Supplement — Preferred Plan Letter

Maximum Monthly Premium Budget

Dental / Vision / Hearing Needed?

Additional Applicants (e.g. spouse, partner — each person gets their own profile)

ℹ️ Medicare is an individual plan — but spouses or partners often shop together. Add additional applicants below and each will get their own medical profile.

Medical Profiles (Per Person — Critical for Part D Formulary & Network Matching)

Preferred Doctors / Specialists (all applicants)

🧑 Primary Applicant — Medical Profile

Current Prescriptions Critical for Part D matching

Ongoing Medical Conditions

Upcoming Surgeries or Procedures

Injuries or Illnesses in the Last 5 Years (that may appear on a medical report)

Additional Information

Low Income Subsidy / Extra Help Eligible?

Medicaid Eligible?

📄

Upload Current Medicare Plan Declarations Page or Summary of Benefits

PDF or image — helps the agent compare your current plan against available options

Additional Notes

ℹ️ By submitting this form you authorize a licensed Medicare insurance agent to contact you regarding coverage options. No coverage is bound until you receive a policy from a licensed carrier.

Life Insurance Term · Whole · Final Expense

Tell us about the coverage you need and we'll connect you with a licensed life insurance agent.

Applicant Information

First Name *

Last Name *

Date of Birth *

Gender

Email *

Phone *

Tobacco / Nicotine Use in Last 12 Months?

Height

Weight (lbs)

Coverage Requested

Coverage Type

Coverage Amount Desired

Maximum Monthly Premium Budget

Purpose of Coverage

Desired Effective Date

Beneficiary

Primary Beneficiary Name

Relationship to Applicant

Secondary Beneficiary (if any)

Relationship

Additional Applicants (e.g. spouse, partner — each person gets their own profile)

ℹ️ Spouses and partners often apply for life insurance at the same time. Add additional applicants below — each will get their own health profile and coverage preferences.

Health Profile (Per Person — Affects Eligibility & Premium Rates)

ℹ️ Life insurance carriers underwrite each applicant individually. Complete as much as you can — your agent will review and advise on the best carriers for your health profile.

🧑 Primary Applicant — Health Profile

Any heart / cardiovascular conditions?

Any cancer history?

Diabetes?

Any neurological conditions?

Any respiratory conditions? (COPD, asthma, etc.)

Any mental health / substance abuse history?

Any hazardous occupations or hobbies?

Any other significant health conditions?

Please describe

Current Medications

Upcoming Surgeries or Procedures

Injuries or Illnesses in the Last 5 Years (that may appear on a medical report)

Existing Life Coverage

Any life insurance currently in force?

Current Carrier

Current Coverage Amount

Current Policy Type

📄

Upload Current Life Insurance Declarations Page or Policy Summary

PDF or image — helps the agent review your current coverage and identify any gaps

Additional Notes

ℹ️ By submitting this form you authorize a licensed life insurance agent to contact you regarding coverage options. No coverage is bound until you receive a policy from a licensed carrier.

Builder's Risk Insurance

Coverage for structures under construction — new builds, additions, and major renovations.

Project Information

Project Type *

Project Address *

City *

State

ZIP Code

County

Project Details

Estimated Completed Value (ECV) *

Total value of the completed structure including all materials and labor

Construction Type

Square Footage

Number of Stories

Project Start Date *

Estimated Completion Date *

Current Stage of Construction

Is Any Portion Currently Occupied?

Occupied structures during renovation may require separate coverage

Describe Occupied Portion

Existing Structure on Site?

Value of Existing Structure

Owner Information

Owner Type

Owner / Entity Name *

Owner Phone *

Owner Email *

Owner Mailing Address

General Contractor

General Contractor Name

GC License Number

GC Phone

GC Email

GC Years in Business

Is Owner Acting as Their Own GC?

Coverage Details

Deductible Preference

Soft Costs Coverage Needed?

Covers permits, architect/engineering fees, financing costs if project is delayed by a covered loss

Estimated Soft Costs Value

Materials Stored Off-Site?

Materials stored at a supplier or warehouse before delivery to the job site

Off-Site Storage Location & Value

Tools & Equipment Coverage Needed?

Flood Coverage Needed?

Wind Coverage Needed?

Prior Insurance & Losses

Prior Builder's Risk Policy in Place?

Prior Carrier

Prior Policy Expiration

Any Losses on This Project to Date?

Loss Detail (date, type, amount)

📄

Upload Prior Builder's Risk Declarations Page

PDF or image — we'll extract carrier, limits, and coverage details automatically

Additional Insureds

Lender / Construction Loan Holder (if applicable)

Lender Address

Additional Insured (GC, property owner, investor — if different from above)

Additional Notes

ℹ️ By submitting this form you authorize a licensed insurance agent to contact you regarding Builder's Risk coverage options. No coverage is bound until you receive a policy from a licensed carrier.

🌊

Request Submitted!

Thank you — your quote request has been received. A licensed agent from our BindFlow network will review your application and reach out within 1 business day.

Questions? Call or text (352) 340-3908