Personal Client Onboarding Form

At Eastman Insurance Solutions, our personal insurance process begins with understanding your household, lifestyle, and the assets you want to protect. Our Personal Client Onboarding Form collects the key information we need to build your file, connect you with the right advisor, and begin evaluating your personal risk profile. By providing these essentials up front, you help us streamline the review process and prepare for a thoughtful, strategic discussion about your coverage.

This short form focuses on the foundational details required to set up your personal account within our system: household information, property and vehicle basics, drivers, current insurance providers, and your coverage priorities. Document uploads are not required at this stage. Once your profile is created, your EIS advisor will walk you through the next step, including reviewing your current policies, identifying gaps, and designing a personalized, high-value protection plan.

This onboarding experience is designed for commercial clients who want a unified advisory relationship across their business and personal portfolios, as well as individuals seeking a higher standard of service and attention to detail. If you value clarity, elevated protection, and an advisor who treats your personal assets with the same care as your business, you’re in the right place.

This process will take you approximately 10 minutes to complete. To alleviate redundant back and forth, please complete in its entirety.

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Step 1 of 4 - General Information

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General Information

First Named Insured*

First Last

Second Named Insured (If Applicable )

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Current Insurance Provider*

What Brought You To Eastman Insurance Solutions?*

Are you seeking Auto, Home or Both*

I am an Existing Client, I need a new Home Policy

I am an Existing Client, I need a new Auto Policy

I am a New Client, I need Both, Home and Auto

Home Information

This Property Is......

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Property Characteristics

Please be as accurate as possible

Year Built*

Square Footage*

List of Updates Of Home Since Original Construction.*

Example: Kitchen Remodel, 2009

Flooring Material?*

Complete to 100% (e.g. Laminate 60%, Tile 20%, Carpet 20%)

Roofing Material*

Solar Panels? If Yes, How Many?*

Fire and Theft Protection Information

Name Of Fire Department*

Fire Hydrant Within 1000 Feet Of Home?*

Yes, Within 1000 Feet

No, Over 1000 Feet

No Hydrant Present

Distance to Responding Fire Station*

Fire Extinguisher Present*

Smoke Detector*

co2 Detector*

Interior Sprinklers?*

Monitored Burglar / Fire Alarm?*

Coverage & Loss History

Current Liability Limits

Med Pay Limit

Desired Deductible

Any Home Claims Filed In The Last 5 Years?*

Yes

Number Of Claims Over 1000 Paid Out?

In the last 5 years

Current Insurance Carrier?*

Current Policy Expiration Date*

MM slash DD slash YYYY

Auto Insurance Section

How Many Drivers?*

Driver #1

Driver Name

Date Of Birth

Month

Day

Year

Age Licensed?

Marital Status

Gender

Occupation

Minor Violations - Last 3 Years

Minor violations include Speeding, Failure to Stop, Failure to Yield, Seatbelt violations etc.

Major Violations - Last 10 Years

Major violations include DUI, Reckless Driving, Speeding Over 100, etc.

Accidents - Last 5 Years

Include ALL accidents regardless of fault.

Driver #2

Driver Name

Date Of Birth

Month

Day

Year

Age Licensed?

Marital Status

Gender

Occupation

Minor Violations - Last 3 Years

Minor violations include Speeding, Failure to Stop, Failure to Yield, Seatbelt violations etc.

Major Violations - Last 10 Years

Major violations include DUI, Reckless Driving, Speeding Over 100, etc.

Accidents - Last 5 Years

Include ALL accidents regardless of fault.

Driver #3

Driver Name

Date Of Birth

Month

Day

Year

Age Licensed?

Occupation

Marital Status

Gender

Minor Violations - Last 3 Years

Minor violations include Speeding, Failure to Stop, Failure to Yield, Seatbelt violations etc.

Major Violations - Last 10 Years

Major violations include DUI, Reckless Driving, Speeding Over 100, etc.

Accidents - Last 5 Years

Include ALL accidents regardless of fault.

Driver #4

Driver Name

Date Of Birth

Month

Day

Year

Age Licensed?

Marital Status

Gender

Occupation

Minor Violations - Last 3 Years

Minor violations include Speeding, Failure to Stop, Failure to Yield, Seatbelt violations etc.

Major Violations - Last 10 Years

Major violations include DUI, Reckless Driving, Speeding Over 100, etc.

Accidents - Last 5 Years

Include ALL accidents regardless of fault.

How Many Vehicles?*

Vehicle #1

Year, Make, Model, Trim

Example: 2015 Lexus 570 Base

VIN (If Available)

This Allows Us To Provide The Most Accurate Rates

Primary Driver Name

Please assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles.

Annual Miles Driven

Annual miles are an important rating factor, please be as accurate as possible.

Comprehensive Deductible

Your out of pocket expense for damage to your vehicle other than Collision

Collision Deductible

Your out of pocket expense for damage to your vehicle from a Collision

Is This Vehicle Financed?

Yes

Leased

Vehicle #2

Year, Make, Model, Trim

Example: 2015 Lexus 570 Base

VIN (If Available)

This Allows Us To Provide The Most Accurate Rates

Primary Driver Name

Please assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles.

Annual Miles Driven

Annual miles are an important rating factor, please be as accurate as possible.

Comprehensive Deductible

Your out of pocket expense for damage to your vehicle other than Collision

Collision Deductible

Your out of pocket expense for damage to your vehicle from a Collision

Is This Vehicle Financed?

Yes

Leased

Vehicle #3

Year, Make, Model, Trim

Example: 2015 Lexus 570 Base

VIN (If Available)

This Allows Us To Provide The Most Accurate Rates

Primary Driver Name

Please assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles.

Annual Miles Driven

Annual miles are an important rating factor, please be as accurate as possible.

Comprehensive Deductible

Your out of pocket expense for damage to your vehicle other than Collision

Collision Deductible

Your out of pocket expense for damage to your vehicle from a Collision

Is This Vehicle Financed?

Yes

Leased

Vehicle #4

Year, Make, Model, Trim

Example: 2015 Lexus 570 Base

VIN (If Available)

This Allows Us To Provide The Most Accurate Rates

Primary Driver Name

Please assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles.

Annual Miles Driven

Annual miles are an important rating factor, please be as accurate as possible.

Comprehensive Deductible

Your out of pocket expense for damage to your vehicle other than Collision

Collision Deductible

Your out of pocket expense for damage to your vehicle from a Collision

Is This Vehicle Financed?

Yes

Leased

Vehicle #5

Year, Make, Model, Trim

Example: 2015 Lexus 570 Base

VIN (If Available)

This Allows Us To Provide The Most Accurate Rates

Primary Driver Name

Please assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles.

Annual Miles Driven

Annual miles are an important rating factor, please be as accurate as possible.

Comprehensive Deductible

Your out of pocket expense for damage to your vehicle other than Collision

Collision Deductible

Your out of pocket expense for damage to your vehicle from a Collision

Is This Vehicle Financed?

Yes

Leased

Vehicle #6

Year, Make, Model, Trim

Example: 2015 Lexus 570 Base

VIN (If Available)

This Allows Us To Provide The Most Accurate Rates

Primary Driver Name

Please assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles.

Annual Miles Driven

Annual miles are an important rating factor, please be as accurate as possible.

Comprehensive Deductible

Your out of pocket expense for damage to your vehicle other than Collision

Collision Deductible

Your out of pocket expense for damage to your vehicle from a Collision

Is This Vehicle Financed?

Yes

Leased

Auto Coverages

Liability Limits Requested*

Average - $100,000/$300,000

Preferred - $250,000/$500,000

Ultra Preferred - $500,000/$500,000

Liability provides coverage for those you injure in an accident, outside of your vehicle.

Property Damage*

Property damage covers the damage you cause to someone else's property in an accident

Medical Payments*

Med-Pay Covers out of pocket medical expenses for injuries sustained by you or other individuals in your car in an accident that is your fault.

Optional Coverages

Rental Reimbursement

Roadside Assistance

OEM Replacement Parts

Full Glass Coverage

Special Equipment

Finalizing

Can we assist you with any other policies?

Umbrella Insurance

Rental Properties/Landlord Insurance

Motorcycle Insurance

Classic/Collector/Exotic Car Insurance

CCW - Firearm Liability/Self Defense Insurance

Business Liability Insurance

Business Property Insurance

Workers Compensation Insurance

Commercial Auto Insurance

Bonds

EIS is a full service insurance agency, with access to over 100 insurance carriers, we can match your insurance needs with the right carrier to assure you are getting the best value for your insurance premium.

Secured Document Upload

Drop files here or

Max. file size: 5 MB, Max. files: 10.

If you have copies of your current insurance coverage, it is extremely helpful if you provide your current insurance docs, this allows us to provide a more comprehensive review.

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**Important: Please note completion of any request(s) for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting a request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the Insurance Company.