Cothran Insurance Personal Lines Pre-Renewal Form

5 Question Pre-Renewal Questionnaire

Policy reviews are a great way to make sure your insurance policies are keeping up with your evolving life. The below information is needed to better discuss your needs during the review. Please complete the below survey form prior to your policy review.
Name *

First Name Last Name
Do you anticipate in the next 12 months, or have you experienced within the past 12 months, any of the below life changes? Please check all that apply. *

Purchase of a new home Retirement Birth of a child Marriage Remodel Existing Home None
Which of the following describes your current living situation? *

Own a Home Own a Condo Own a Townhome Own a Mobile Home Rent Other
Do you have any life insurance outside of work? *

Yes No
The next two questions are so that we can make sure your liability limits are adequate based off of your income and net worth. Liability insurance is cheap, but having insufficient liability limits can be expensive.
What is your household's annual income range? *

Less than $25,000 $25,001 to $50,000 $50,001 to $100,000 More than $100,000
What is your net worth? *

Less than $100,000 $100,001 to $250,000 More than $250,000
Optional: Please describe any coverages or other specific concerns you wish to address during the meeting.
Should be Empty:

5 Question Pre-Renewal Questionnaire