It's time for an Insurance check-up. To better serve you and to help eliminate gaps in your insurance coverage, we developed this questionnaire. We will use the information you provide here to evaluate the adequacy of your present coverage and will advise you of any changes that may be in order. This information is kept private, as detailed in our Privacy policy.
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Full Name |
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| Address |
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Address 2 |
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City |
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State |
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Zip |
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Mailing Address
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Mailing Address 2 |
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Zip |
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Email |
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| Daytime Phone: |
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| Home Phone: |
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| Work Phone: |
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YES NO |
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Are there any corrections or changes to the address or location of your home as shown above? |
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| 2 |
Does anyone, except a mortgagee listed on your policy, have a financial interest in your home? |
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| 3 |
Do you have any outbuildings or separate garages? |
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Do you own or rent any other real estate, by yourself or with others? |
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Do you serve on any charitable, social or governmental boards? |
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Have you done any remodeling or made other improvements to your home? |
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Is the amount of insurance on your home less than it would take to rebuild it? |
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| 8 |
Are your personal belongings covered for less than it would cost to replace them in a total loss? |
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| 9 |
Do you have collectibles such as antiques, fine art, stamps, or coins? |
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Do you own tools, equipment or other property used in your trade, business or profession? |
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Do you do any work at home? |
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Do you own expensive jewelry, furs or silverware? |
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Do you own costly sporting equipment, guns, hobby equipment or musical instruments? |
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Do you own a boat, jetski, or waverunner? Ever rent them? |
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Do you ever keep or carry cash over $200? |
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Are you interested in doing a video inventory of your home? |
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Do you own a golf cart, go-cart, dirt bike, ATV, snowmobile, dune buggy, hovercraft or any other self-propelled vehicle including riding lawn mowesr, garden tractors or scooters? |
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| 18 |
Do you need coverage for flood or earthquake? |
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| 19 |
Do you have any employees? |
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Do you own any cars, trucks, motorcycles, motorhomes, campers or trailers not shown on a policy with us? |
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Do you often drive vehicles owned by others, including an employer's vehicle? |
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Are there any non-family members living with you? |
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Do you ever use your vehicles for business reasons? |
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Do you ever rent cars? |
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Do any of your vehicles have custom equipment? |
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Do you own any other personal property valued over $1000 per item not mentioned above? |
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Are you interested in increasing your liability coverage? |
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Do you need to review your life insurance coverage? |
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Would you like information on disability coverage? |
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Would you like information on medical insurance? |
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Do you have any questions about your insurance coverage? |
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Message
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