00 /

Call Details

Compliance — fill before dialing

Call Date

Call Time

Telemarketer

Lead Source

Lead Type

Cole X-Date Internet Lead Referral Other

Internet Lead Vendor

Recording Disclosure (Illinois 2-party consent — required)

Disclosure given, prospect OK Prospect declined — recording stopped

TCPA consent — verbally confirm with prospect, then check the boxes below.

Consent to Quote — prospect agreed to share info for a quote

Consent to Follow-up — prospect OK with future calls/emails/texts from Merrill

01 /

Prospect Information

First Name *

Last Name *

Date of Birth

Phone (Primary) *

Alternate Phone

Email *

Marital Status

Best Time to Call Back

Occupation

02 /

Address

Mailing / Home Address *

City

State

ZIP

Years at Address

Garaging Address (where vehicle is kept overnight)

Same as home address Different address

Garaging Street Address

City

State

ZIP

04 /

Drivers

Primary + any additional household drivers

05 /

Vehicles

06 /

Driving History

Last 5 years — all drivers

At-fault accidents in last 5 years?

Yes No

Details — driver, date, description, claim amount

Not-at-fault accidents in last 5 years?

Yes No

Details — driver, date, description

Speeding tickets / moving violations in last 5 years?

Yes No

Details — driver, date, type, MPH over (if known)

DUI / DWI / reckless driving (any time)?

Yes No

Details — driver, date, disposition

License suspensions in last 5 years?

Yes No

Details — driver, date, reason

07 /

Current Auto Insurance

Current Carrier

Renewal Date (X-Date)

Years Continuously Insured

Current Monthly Premium ($)

Bodily Injury Limits

Property Damage Limit

Comprehensive Deductible ($)

Collision Deductible ($)

Has Uninsured Motorist coverage?

Yes No Not sure

Any lapse in coverage in last 12 months?

Yes No

09 /

Notes & Disposition

Telemarketer Notes — anything the agent should know

Disposition

Live Transfer to Agent Email Transfer to Agent Callback Scheduled Not Interested DNC Requested

Callback Date / Time

Assigned Agent

Compliance reminder This form contains PII. Save it to the CRM only — never email, text, or store on a personal device. After submission, clear the form before the next call.

Quote for [ no prospect entered ]

\u2713

Sent to HubSpot

Quote for [name] has been saved.

View quote summary

Call Details

Prospect Information

Address

Housing

Drivers

Vehicles

Driving History

Current Auto Insurance

Discounts to Check

Notes & Disposition

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