Personal Insurance Checkup
First Name: *
Last Name: *
Address: *
City: *
State: *
Zip: *
Day Phone: * (xxx-xxx-xxxx)
Email: *
 
Please review the following questions and answer them as best as you are able.
Property Insurance
1.) Have you done extensive remodeling or have you had structural changes or additions to your home in the last year? Yes      No
 
2.) List the year when the following systems have been upgraded or replaced:
Roof: Electrical:
Furnace: Plumbing:
   
3.) Do you have an activated central station alarm system that will automatically call the police or fire department? Yes      No
4.) If you don't already have sewer back up coverage or sump pump failure coverage would you be interested in adding it? Yes      No
5.) Do you own any property with siblings that was inherited, have vacant land, condos, ownership of portions of real estate investments, etc.? Yes      No

6.) Coverage for certain items listed below are limited in the amount of coverage on your homeowners' policy (example: breakage) and should be considered for additional coverage. These coverages may vary by insurer and change from time to time.  Would you like to know more about any of the following items:

Jewelry limits above $1000.00. Yes      No

Silverware, guns, and coin collections. Yes      No

Antiques and fine arts.  Yes      No

Business contents at home.  Yes      No

Boats, jet skis, snowmobiles, ATVs, fish houses, trailers, etc. Yes      No
7.) Do you operate a business out of the home?


Yes      No

If yes, please explain:
8.) Increasing your deductibles can save money on your premiums. Are you interested in hearing how it could affect your premium? Yes      No
9.) Do you believe, and are you comfortable that your home is to 100% of its replacement cost? Please call with any questions regarding this. Yes      No
 
Auto Insurance:
1.) Do we insure all the vehicles titled in your name? Yes      No
2.) Are all licensed drivers residing in your home listed on your policy? Yes      No
3.) Do you anticipate adding a young driver in the next year? If so, please call to review. Yes      No
4.) If you have young drivers, they may get credit for good grades. Do they have a B (3.0) average? Have you sent us the most recent report card? Yes      No
5.) If you are over 55, have you attended a defensive driver course? The savings are approximately 10% to the vehicle you are assigned to. Yes      No
6.) Are your limits at 100/300/50 or lower? We encourage you to explore higher limits. Yes      No
7.)Are you interested in a $1,000,000 umbrella policy? Yes      No
8.) Would you be interested in learning how we can help with the following types of insurance: auto, home, cycle, boat & recreational vehicles, health, and life? Yes      No
9.) Do you have any changes or questions regarding coverages that have not been addressed? Yes      No
10.) Do you have any suggestions on how we can improve on servicing your account?
 

Once you are certain the information you entered is correct, click the Submit button to send your information to an agent.