New Allstate Customer Bind Date: ____________

Thank You Card Mailed: ____________

Customer Name: -
________________________________________________________________________
Customer Phone #/Phone Type:
__________________________________________________________
Residence/Mailing Addresses Will Need Updated: Yes or No
eSign or Mail Packet or Signed in Person
Bank/ Routing #: _____________________________________ Account #:
________________________
Debit/Credit Card #: _________________________________ Expiration Date:
___________________

New Auto Policy: AFCIC or Indemnity Effective Date:

_____________________
Collected Down Payment or COD
Pay Plan: EZPay Recurring Debit/Credit Card
Withdraw Day: _____
Monthly Pay in Full Direct
Bill
DriveWise Program: Yes, All Vehicles Yes, Only
________________________ No
Declared Coverage in CCDB: No or Yes, and POP is
Attached
Trailing Documents: Med Pay Rejection or Un/Under Insured
Rejection

New Property Policy: Homeowners or Renters or Condo Effective

Date: ______________

Collected Down Payment or COD

Pay Plan: EZPay Recurring Debit/Credit Card
Withdraw Day: _____
Monthly Pay in Full Escrow Account
Direct Bill
Homeowners:
_____ Explained there would be an inspection: the coverage/rate
may increase/decrease, and we will address any
hazards found.
_____ Explained we may need POP Property Coverage
POP HO _____ Attached POP Property Coverage
_____ Didnt Declare Prior Property Coverage,
None/No Need
Roof newer than Move in Date?
____Yes, explained we will need a copy of final bill or cert.
of completion

Thank You Card Mailed: ________Inspection Completed: ________ HO POP Due:

________
Trailing Docs Submitted: ________ HO POP Submitted: ________
New Allstate Customer Bind Date: ____________
Thank You Card Mailed: ____________
New Other Policy: __________________________________ Effective Date:
____________________
(Motorcycle / PUP / Landlords / Secondary Home / Boat /
Etc.)
Collected Down Payment or COD
Pay Plan: EZPay Recurring Debit/Credit Card
Withdraw Day: _____
Monthly Pay in Full Escrow Account
Direct Bill

New Other Policy: __________________________________ Effective Date:

____________________
(Motorcycle / PUP / Landlords / Secondary Home / Boat /
Etc.)
Collected Down Payment or COD
Pay Plan: EZPay Recurring Debit/Credit Card
Withdraw Day: _____
Monthly Pay in Full Escrow Account
Direct Bill

Needs Faxed/Emailed:
___________________________________________________________________
(Example: Renters Dec Pg / 816 555 5555, EOI /
dumb@mortgage.com)
_____ Set the expectation that we would be scheduling an appointment to
discuss life ins.
Notes:
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
_____________________________________________

Thank You Card Mailed: ________Inspection Completed: ________ HO POP Due:

________
Trailing Docs Submitted: ________ HO POP Submitted: ________