QC File Submission Insurance

Insured Name*
First Last
Insured Gender*
- Male
- Female
Date Of Birth - Insured*
MM slash DD slash YYYY
Insured Familial Status*
- Married
- Single
- Divorced/Widowed
Insured Email*
Insured Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Co Insured Name
First Last
CoInsured Gender
- Male
- Female
Co Insured Familial Status
- Married
- Single
- Divorced/Widowed
Co Insured Email
Date Of Birth - CoInsured
MM slash DD slash YYYY
Homeowner or Renter*
- Homeowner
- Renter
Policy Type*
- Auto
- Home
- RV
- Motorcycle
- Travel Trailer
- Umbrella
- Commercial Auto
- BOP
- Home and Auto 1 Carrier Combo
Please complete this form for EACH policy sold. For a home and auto you would submit this form 2 times.
Name Of other People on Policy*
First Name Last Name Relation

@Name Of Other People On policy: If other people what is the relation to the primary and secondary policy holder? @Relation of other people to D1/D2:. QUALITY CONTROL NOTES: If other people what is the relation to the primary and secondary policy holder? Input None, None, None if None other than insured/co insured.
Excluded Drivers*
First Last Reason Excluded

&Any drivers Not on policy but living at address? Yes / No If yes Flag for review by Mgt. &Name and whats the relation? &Why are they not listed and/or Rated/excluded? QUALITY CONTROL NOTES. Input None, None, None if none are excluded. EXCLUDED DRIVER FORM REQUIRED TO BE SIGNED BY PRIMARY INSURED.
Drivers Not On Policy Or Excluded/Rated*
First Last Relation Reason Not Listed

&Any drivers Not on policy but living at address? &Name and whats the relation? &Why are they not listed and/or Rated/excluded? QUALITY CONTROL NOTES. If yes Flag for review by Mgt.
Effective Date of policy*
MM slash DD slash YYYY
Effective Date of policy Home for Combo
MM slash DD slash YYYY

If home and Auto input the effective date here if it is different from the auto policy.
Date Of First Payment Received*
MM slash DD slash YYYY
Date Of First Payment Received If home and auto combo
MM slash DD slash YYYY

If home and Auto combo with 1 carrier input the data requested here.
Down Payment Paid By
- Credit Card
- EFT
- Check Received
- Billed to Mortgage Company
First Payment Amount*
First Payment Amount Home Auto Combo - Home
If home and Auto combo with 1 carrier input the data requested here. First payment on the home insurance.
Total Policy Premium*
Home Policy Premium - Home/Auto 1 Carrier - Home Premium
If home and Auto combo with 1 carrier input the data requested here. Insert only the Home premium in this field. The field above it should be the total for the auto policy.
Pay Mode*
- Monthly
- Quarterly
- Semi Annual
- Annual
Payment Plan*
- Paid In Full
- Installment Plan
Payment Plan - Home/Auto Combo - Home Portion*
- Paid In Full
- Installment Plan
If home and Auto combo with 1 carrier input the data requested here. payment plan with home policy
Payment Process*
- Auto Pay
- Direct Bill
Payment Process - Home/Auto - Home Portion
- Auto Pay
- Direct Bill
If home and Auto combo with 1 carrier input the data requested here.
Are they Set Up for Auto Pay On Carrier Site*
- Yes
- No
Are they Set Up for Auto Pay On Carrier Site - Home/Auto - Home Portion
- Yes
- No
If home and Auto combo with 1 carrier input the data requested here. Home portion
Sign Type*
- Cuda ESign
- Carrier Esign
- Fax and Return
- Mail and Return (Done by agent only)
- Email and Return
PIP Medical Type*
- Primary
- Coordinated
QUALITY CONTROL: If Coordinated PIP form must be signed. Plus we need a letter from the Health Insurance Company.
What kind of medical insurance does client have?*
- Medicare/Medicaid
- No Health Insurance
- Employer Provided Health
- Exchange Provided Health
QUALITY CONTROL: If the response is Medicare/Medicaid/ No Health they cannot be coordinated. If the client is on Medicare/Medicaid/NO Health they cannot be coordinated on their Auto Policy. If response is Employer or Exchange, further research is required to determine if the coverage is coordinated.
Did you view the health insurance card prior to binding?*
- Yes
- No
You must VIEW the health card PRIOR to binding the policy, if the health insurance coverage is Coordinated
If coordinated, did you read required script?*
- Yes
- No
QUALITY CONTROL: RESPONSE must be yes, do not bind unless yes. If response is NO, the commissions are not payable on said files. Required Script PRIOR to Binding: "Since you have requested to be Coordinated with your health coverage and you choose to decline Primary coverage for your Personal Injury Protection, you may not be covered by your auto or health insurance company in the event of an accident. Also, it is your responsibility to maintain that health insurance policy. If your health insurance policy changes and it will no longer remain primary It is your responsibility to contact us and request your coverage to be changed from Coordinated to Primary within 24 hours of the change. do you have any questions or concerns with this statement?"
What was their Response to question, How do you know you're health insurance is coordinated?*
Please type their response to your required question - How do you know you're health insurance is coordinated?
how do YOU KNOW for a FACT that their Health insurance is Coordinated?
Please explain what you did to follow up on their health insurance policy coordination. How did you underwrite the coordination of Health Insurance? In other words, how do YOU KNOW for a FACT that their Health insurance is Coordinated?
Employer Name*

What is the Employer Name? (If health insurance is coordinated this question is required) If they are not on an employer plan, you may Type "Exchange" or the type of plan they have.
Who is the customers Health Insurance Company?*
Health Insurance Group Number*
What is the Health Insurance Group number from the health insurance card?
BI-Liability*
- 20/40 Only Arrowhead
- 25/50
- 50/100
- 100/300
- 250/500
- 500/1000
- 100k-299k Home
- 300K+ Home
Do Not Sell less than 100/300, unless previously uninsured and we put it through arrowhead. Do not sell less than what the client currently has.
UM*
- 20/40
- 25/50
- 50/100
- 100/300
- 250/500
- 500/1000
- None - Not allowed Do Not Sell
UM and UIM are required. Do not sell any policies without this coverage. Customers don't understand how important this coverage is. We must protect them, and if they will not allow us to then we will not take them on as a client.
Collision Coverage Type*
- Broad
- Basic
- Limited
- None
QUALITY CONTROL: If None a signed collision form must be on file. Check shared drive for proof of signed collision doc.
Collision Deductible
- Deductible $1-500
- Deductible $501-1000
- Deductible $1001+
Comprehensive Deductible
- Comprehensive Not Accepted
- Deductible $1-500
- Deductible $501-1000
- Deductible $1001+
Was Rental Coverage Offered?*
- Yes
- No
Rental Coverage must always be offered. Potential E and O concerns.
Has Group Discount Been Provided?*
- Yes
- No
@@Has Group Discount Been Provided List or None List Member of _________________________ If no group discount was provided then no proof is needed.
Group Name*

If none place 'None' in field.
Proof Of Prior Insurance*
- Received: To be uploaded to AMS
- Still Getting (customer understands rate may go up)
- Clue Report Shows Proof (Printed and in file)
- Not Required
DO NOT BIND UNTIL WE HAVE PROOF OF PRIOR. SELECTING 'STILL GETTING' IS A QC FLAG.
Reason Proof Of Prior is Not Required*
- Did not have car. and bought new car
- Did not have prior, but it was required
- Formerly on parents policy. (we need proof)
CARRIER BOUND THROUGH*
- PROGRESSIVE
- MERCURY
- ALLIED (V)
- GRANGE
- FOREMOST
- NATIONAL GENERAL
- SAFECO
- MICHIGAN BASIC
- WOLVERINE
- GREAT LAKES MUTUAL
- MICHIGAN PLACEMENET FACILITY
- ALLSTATE (GLAI)
- ENCOMPASS
- HARTFORD
- TITAN
- ARROWHEAD
- Allied - Nationwide (FOR GLAI Only)
- ASI Progressive Home
- Universal Property (Cranbrook)
- Universal Property (Delta)
POLICY NUMBER
POLICY NUMBER - Home/Auto - Home Policy No

If home and Auto combo with 1 carrier input the data requested here.
Producer Name*
- Barbara Jetmore
- Jeffrey Hillock
Sales Rep Email*
Producer Split
Producer Name Producer Split Percentage

What percentage is Theirs and yours. Leave blank if not a split
Source Of Business*
- Telemarketing 2301
- Referral From Existing Customer
- Referral from Car Dealer
- Referral from Mortgage Rep
- Referral from Other
- Internet Lead
- Walk In
- 2500 Prior Quotes
- Previous Customer
Home Questions*
- Yes
- No
Did you ask all the appropriate questions about the home, Dog Breeds, Trampoline, Pool, roof condition, outbuilding condition? And include these responses in the quote?
Roof Condition*
- Good
- Acceptable
- Poor/Not Acceptable
Is there a trampoline on the property*
- Yes, Rated and Acceptable to Carrier
- No
- Yes, Not Rated, Not Acceptable to Carrier.
Please note that some carriers will decline coverage if there is a trampoline and/or require a rating.
Is there a pool on the property*
- Yes
- No
Please note that some carriers will decline coverage or require a rate for the pool.
Was the pool rated on the policy?*
- Yes
- No
did you include the pool in the quote?.
Does the client have a dog?*
- Yes
- No
Please note that some carriers will decline coverage if there is a non acceptable dog breed. Not disclosing properly could cause E and O issue, or it could cause us to lose our appointment.
Is the Dog an acceptable breed to the Carrier?*
- Yes
- No
Please note that some carriers will decline coverage if there is a non acceptable dog breed. Not disclosing properly could cause E and O issue, or it could cause us to lose our appointment.
Home Photos for home policies (PRIOR TO BIND)*
- Yes, Photos Inspected and home is in near perfect condition
- No
- Received signed letter from customer
Please Certify that you have inspected the home and placed photos that are less than 1 day old of the home in the file PRIOR to binding. Also certify that after inspecting a photo of the home that the home is in near perfect condition with no flags. If you did not get photos, please certify that the customer signed the claims may be denied letter until inspection.
Prior to Bind Requirements NOT Met.*
- DO NOT BIND THIS POLICY.
Please Certify that you have inspected the home and placed photos that are less than 1 day old of the home in the file PRIOR to binding. Also certify that after inspecting a photo of the home that the home is in near perfect condition with no flags. If you did not get photos, please certify that the customer signed the claims may be denied letter until inspection. You must rate the pool if it was not, if it was make sure the question indicates. The dog breed must be acceptable, and research must be done with carrier PRIOR to binding. the condition of the roof must be acceptable or brought up to acceptable prior to binding. You must certify you asked all the Home questions, Prior to binding. You must rate the trampoline and verify its acceptable to the carrier.
Rating Accuracy Confirmation*
- Yes
- No
(select 'Yes' to confirm that the policy is rated accurately and based on professional recommendations and non fraudulent selections either by agent or policyholder)
Was this application taken directly from one of the applicants or insureds?*
- Yes
- No
If no, you must contact the insured and ask all the questions all over again and cancel the existing policy if it was bound. There are legal issues pertaining to this, potential fraud can occur without the knowledge of the insured or agent. It is your obligation to protect the insured. The risks are high with this QC point.
Quality Control*

Please Read this statement, and type 'i certify' in the space provided. If not, put 'NO'. This file does not have any discounts that are not provable. This file does not have any fraud. I fully disclosed all coverages that the client has as well as disclosed the coverages that the client should have, (UM, UIM, COLL, Comp, Rental, Primary/Excess). Please certify the quality. Remember, its not worth a problem for you or the customer if a claim is denied for rating issues. It is your responsibility to get it right.
Comments
Agents - please review pipeline daily, if processor has any trouble getting documents please help. Processor must solicit your support every Friday with files not received for 5 or more business days. Agents responsibility is to provide the documents. Commissions are payable once the file is fully cleared. -Agent shall fill out this form -Agent Shall Send for esign for Progressive and Mercury -Agent shall collect first payment and set up EFT (IF EFT) on all carriers. -Agent shall set up Auto Pay EFT for all carriers if customer elects auto pay. -1st payment Options: Progressive CBP Only, Mercury Credit or CBP, Foremost Credit or CBP, Allied Credit or CBP -Auto Pay Options: Only Check By Phone for All Carriers -Agent shall collect 1. Proof of prior unless not required, 2. Medical Card if coordinated, 3. Proof of Membership 4. Pictures of all sides and corners of house if homeowners policy. 5. Prepare customer to sign/esign documents. 6. Send Client Detail Form to Voldico. 7. Review pipeline for completion of signatures. 8. Ensure rating accuracy. 9. Ensure customer is low risk to carrier 10. ensure quality control form is completed. 11. Service customer as necessary. -Send all to pbeltran@cranbrookloans.com within 24 hours from the closing for processing.
Is their NEW Coverage Lower Than Their Current Coverage*
- Lower Coverage
- Equal To Previous
- Higher Coverage
This Causes an issue for E and O purposes, if the answer to this question is yes you MUST document the reason new coverage is lower. And you must document in AMS notes that you discussed this with the client and that they know about the lower coverage and accept it.
QC Form Completion Within 24 Hours*
- Yes
- No
Has this form been completed within 24 hours of the sale? It is required that this form be completed within 24 hours of making the sale.
Notes

First Name	Last Name	Relation

First	Last	Reason Excluded

First	Last	Relation	Reason Not Listed

Producer Name	Producer Split Percentage

QC File Submission Insurance

QC File Submission Insurance

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