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Please update any question which you have not notified your insurance provider about in the past year.
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Personal and Contact Information
Please provide your most up-to-date contact information.
Please provide your name
*
First Name
Last Name
In the past 12 months, have you had a legal name change due to an event such as a change in marital status, etc?
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Yes
No
Please provide your updated name
First Name
Last Name
Has your address changed in the past 12 months?
*
Yes
No
Please confirm your current address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Nebraska
Nevada
New Hampshire
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New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please provide your email address
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example@example.com
Please provide your phone number
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Please enter a valid phone number.
What is your desired method of communication?
*
Please Select
Phone
Text
Email
Social Media
Mail
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Select Policies
Please select each of the policies you have with your agent or company
Select each policy that you have with your agent or company
*
Homeowners
Automobile
Life
Umbrella
Motorcycle
Renters
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Update Your Files
Update Your Home Insurance
Please answer the questions based on the past 12 month activities.
In the past 12 months, as anyone moved in or out of your home?
*
Yes
No
Please provide the name of the person that has moved in or out of your home
First Name
Last Name
Please provide the relationship if any to the individual
In the past 12 months, have you installed any type of security system or fire alarm to your home?
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Yes
No
Please name the service provider
Are you able to provide a proof of certificate of installation?
Yes
No
Are you currently or do you have plans to rent any part of your home and/or garage either on a long term or short term basis?
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Yes
No
Please provide the name of the individual renting any part of your home
First Name
Last Name
In the past 12 months, have you or any member of your household started a business in your home?
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Yes
No
Please best describe the type of business
Because of the business, do clients, customers, or the general public visit your home for any reason?
Yes
No
Please select the insurance coverages you have for this home based business
General Liability
Property and/or Business Property
Workers Compensation
Business Auto
In the past 12 months, have you installed or purchased any of the following items
*
None of these apply
Above Ground Pool
Trampoline
In-Ground Pool
Jacuzzi / Hot Tub
Please select each of the items included with your pool
Diving Board
Slide
My pool in completely fenced
Gates to my pool can be locked
Does your above ground pool have any of the following items?
Slide
My pool has a fence with locking gates
My pool has a ladder with a locking gate
Can your jacuzzi or hot tub be locked?
I have a locking cover
I do not have a locking cover
Is your trampoline netted?
My trampoline has a net that surrounds it
My trampoline does not have a net
In the past 12 months, have you taken any of the following financial actions on your home
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I have not made any changes
I have paid off my mortgage
I have refinanced my home
I have obtained a second mortgage
I have obtained a home equity line of credit
In the past 12 months, have you completed significant improvements to any of the following items for your home
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None of these apply
Heating and Air / HVAC
Plumbing
Roof
Electrical
Built on to your home
Finished an attic or basement
Added a detached structure
Please best describe the improvements that have been completed
In the past 12 months, have you purchased any of the following types of properties
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Second / Seasonal Home
Rental Property
Investment Property
Vacant lot or land
I have not purchased any new properties
Please provide the address of the property purchased
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
In the past 12 months, have you acquired any pets or animals?
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I have no new animals
Cat
Dog
Other
Please provide the breed of the animal
In the past 12 months, have you acquired or purchased any of the following items?
*
Artwork
Jewelry
Furs
Firearms
Other type of collectible
None of these apply
Please describe the item(s) and its value
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Update Your Auto Insurance
Please answer the questions based on the past 12 month activities.
Have you purchased or sold a vehicle which needs to be removed or added to your policy?
*
Yes
No
The following vehicle needs to be
Added
Removed
Year
Make
Model
VIN (if known)
Do you currently own or lease a vehicle not listed on your auto insurance policy?
*
Yes
No
Please provide the reason the automobile is insured elsewhere
Insured through my lease company
Insured on another policy
Not insured at all
Vehicle is inoperable
Vehicle Info Insured Elsewhere
Does any person not listed as a driver on your personal auto insurance policy have regular access to any automobiles insured on your auto insurance policy?
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Yes
No
Name of driver with regular access
First Name
Last Name
Reason for access and use
Approximate amount of use
Daily
Weekly
Twice per month
Once per month
Is any vehicle insured on your auto insurance policy used for delivery or business use? (Uber, Lyft, DoorDash, etc)
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Yes
No
What type of use is your vehicle used for?
Grocery Delivery
Food Delivery
Moving of People (ie Uber / Lyft)
Professional Use (ie - Real Estate)
Information of vehicle used
Is there a licensed member of your household that not listed as a driver on your current auto insurance policy?
*
Yes
No
Please provide the reason why this driver is not currently listed on your auto policy
Driver is insured on another policy
Driver has just obtained license
Driver has his/her own auto insurance
Driver has no insurance
In the past 12 months, have you paid a loan off on any vehicle listed on your auto insurance policy?
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Yes
No
Please list the vehicle that has been paid off
In the past 12 months, has any licensed driver listed on your policy moved to college which is at least over 100 miles away from your home without a vehicle?
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Yes
No
Please provide the name of the driver
First Name
Last Name
In the past 12 months, have you or any driver listed on your personal auto insurance policy changed jobs or started working from home which has resulted in an increase or decrease in your daily miles driven?
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Yes, increased miles driven
No, there has been no change
Yes, decreased miles driven
Name of driver whose mileage has changed?
First Name
Last Name
Primary Vehicle Driven
Updated Miles Driven (One Way)
Is any vehicle listed on your policy not garaged at your primary address
*
Yes
No
Please list the vehicle not garaged at your primary address
Please list the address in which the auto is garaged
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Next
Update Your Life Insurance
Please answer the questions based on the past 12 month activities.
In the past 12 months, has your marital status changed?
*
Yes
No
Please select your current marital status?
Single
Married
Widow / Widower
Divorced
Due to this change, do you need to update your beneficiary(ies) on your current life insurance policy?
Yes
No
Name of new Beneficiary
First Name
Last Name
Please provide your relationship to your new Beneficiary
Spouse
Child
Relative
Other
In the past 12 months, have any children been added to or left the household?
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Yes
No
Do you believe this change has increased or decreased your need for life insurance?
Increased my need
Decreased my need
My need has not changed
I am uncertain
In the past 12 months, has your overall health status improved?
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Yes, it has improved
No, it has not improved
Because of this improvement, would you like to review your eligibility status for life insurance?
Yes, please contact me
No, not at this time
In the past 12 months, have you discontinued the use of tobacco products?
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Yes, I have
No, I have not
This does not apply to me
How long have you discontinued your used of tobacco products?
1 - 4 months
4 - 8 months
8 - 12 months
More than 12 months
Do you need to add, remove, or change a beneficiary on your life insurance policy?
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Yes, I do need to make a change
No, I do not need to make a change
I need to make the following change
Add a beneficiary
Change a beneficiary
Remove a beneficiary
Name of beneficiary to be added or removed
First Name
Last Name
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Next
Update Your Motorcycle Insurance
Please answer the questions based on the past 12 month activities.
Have you purchased or sold a motorcycle which needs to be removed or added to your policy?
*
Yes
No
The following vehicle needs to be
Added
Deleted
Year
Make
Model
VIN (if known)
Do you own or lease a motorcycle not listed on your auto insurance policy?
*
Yes
No
Why is it insured elsewhere
Insured through my lease company
Insured on another policy
Not insured at all
Motorcycle is inoperable
Year
Make
Model
Does any person not listed as a driver on your motorcycle policy have regular access to any motorcycle insured on your policy?
*
Yes
No
Name of driver with regular access
First Name
Last Name
Reason for access and use
Approximate amount of use
Daily
Weekly
Twice per month
Once per month
Is there a member of your household with a motorcycle endorsement that is not listed as a driver on your current motorcycle insurance policy?
*
Yes
No
Please provide the reason this driver is not currently listed on your motorcycle policy
Driver is insured on another policy
Driver has just obtained license
Driver has his/her own auto insurance
Driver has no insurance
Have you paid a loan off on any motorcycle listed on your insurance policy?
*
Yes
No
Year
Make
Model
Have you or any driver listed on your motorcycle insurance policy changed jobs or started working from home which has resulted in an increase or decrease in the daily miles driven?
*
Yes
No
Name of driver whose mileage has changed?
First Name
Last Name
Primary Motorcycle Driven
Updated Miles Driven (One Way)
Is any motorcycle listed on your policy not garaged at your primary address
*
Yes
No
Please list the motorcycle not garaged at your primary address
Please list the address in which the motorcycle is garaged
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is there any time period during any 12 month period in which you do not operate your motorcycle?
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Yes, I do not operate my motorcycle 1 - 2 months our of the year
Yes, I do not operate my motorcycle 2 - 3 months our of the year
Yes, I do not operate my motorcycle 3 months our of the year
No, I operate my motorcycle year round
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Update Your Umbrella Insurance
Please answer the questions based on the past 12 month activities.
Have there been any changes to the number of motorized vehicles which are licensed for road use owned, leased, or regularly operated by you or any member of your household in the past 12 months?
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No, there have been no changes
Yes, there have been changes that have not been reported to my agent or company
Have there been an increase or decrease in the number of licensed drivers in your household? (This includes any member of your household with a learner’s permit or a valid driver’s license)
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No, there have been no changes
Yes, there have been changes that have not been reported to my agent or company
Have there been any change in the number of watercraft owned or regularly operated by you or any member of your household?
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No, there have been no changes
Yes, there have been changes that have not been reported to my agent or company
Have you or any member of your household began an occupation of a professional entertainer, professional athlete, media personality, non-remunerative or an appointed or elected federal or state political figure in the past 12 months? (N/A for political figures in FL, OR & TX)
*
No, none of these apply to member of my household
Yes, one or more of the conditions apply to a member of my household
Have you or any other member of your household had an arrest, citation or conviction for reckless driving, careless driving, negligent driving, driving under the influence, driving while intoxicated, or had a driver's license suspended?
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No, none of these apply to member of my household
Yes, one or more of the conditions apply to a member of my household
Have you or any member of your household been indicted, charged with or convicted of a felony in the past 12 months?
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No, none of these apply to member of my household
Yes, one or more of the conditions apply to a member of my household
Have you or any member of your household purchased any residential properties owned or rented by you or any member of your household which are located outside Canada, Puerto Rico or the U.S. (including U.S. territories and possessions) in the past 12 months?
*
No, none of these apply to member of my household
Yes, one or more of the conditions apply to a member of my household
Have you or or any member of your household purchased (including partial ownership) any residential properties rented to others in the past 12 months?
*
No, none of these apply to member of my household
Yes, one or more of the conditions apply to a member of my household
Have there been any civil suits brought against any member of your household in the past 12 months?
*
No, this does not apply to member of my household
Yes, this does apply to a member of my household
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Next
Update Your Renters Insurance
Please answer the questions based on the past 12 month activities.
Have you had a resident or roommate of your home move in or out in the past 12 months?
*
No, no one has moved in or out of my home
Yes, I have had a change in household members
Please select which option fits the change in your household members
Moved-In
Moved-Out
Name of the person
First Name
Last Name
Have you subleased or rented any part of your home in the past 12 months?
*
No, I am not currently subleasing or renting any part of my home
Yes, I am currently subleasing or renting any part of my home
Please list the individuals name in which you are subleasing to
First Name
Last Name
Have you added furniture, home goods, electronics, or any other purchase that would require an increase to your personal property coverage amount?
*
No, I have not made any purchases that would change my overall needs
Yes, I have purchased items which have increased my need for more protection
Please provide the details of your purchase(s) and the value(s) of the purchase(s)
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Final Comments, Questions, Concerns
How pleased are you with the service we are providing you?
Please Select
1 - Not Pleased at All
2
3
4
5 - Satisfied
6
7
8
9
10 - Great Service
How likely are you to refer us to others?
Please Select
Likely
Possibly
Not Likely
Would you like to be contacted about any other insurance coverages?
*
Not at this time
Home
Auto
Life / Long Term Care / Disability
Renters
Motorcycle
Watercraft
Other Insurance Products
Please provide any additional information, questions, or concerns regarding your insurance coverages. If you do not have any additional comments, please simply click the Update Your File button.
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