Annual Personal Questionnaire

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number* This field is required.

Please enter a valid phone number.

4

Auto claims are becoming more expensive. Would you like to review or increase your automobile liability limits? * This field is required.

YESNO

5

Do you have any vehicles in your household that are not currently listed on your auto policy and need coverage quoted?* This field is required.

YESNO

6

Do you have any drivers living in your household who are not currently listed on your auto policy?* This field is required.

YESNO

7

Do any of your vehicles have customized equipment that you would like coverage quoted for? -- Examples include but are not limited to: custom wheels or tires, custom interior, speaker systems, truck racks or rollbars, winch systems, external gas tanks, electronics, tonneau bed covers, truck bed liners (including spray-on), etc.* This field is required.

YESNO

8

Do you own any pickup campers, camper shells or toppers, motorhomes, travel trailers, or any other trailers, that need coverage quoted?* This field is required.

YESNO

9

Are any vehicles in your household used for business purposes, including occasional deliveries or carrying passengers for a fee. -- Examples include but are not limited to: Uber, Lyft, Door Dash, Postmates, and similar services.* This field is required.

YESNO

10

Are any vehicles in your household used to drive on behalf of an employer? --Examples include but are not limited to: running errands, carrying passengers, delivering pizza or other food items, etc.* This field is required.

YESNO

11

Auto CommentsPlease provide details for any "Yes" answers.

12

Building costs have increased in recent years and it is important to keep your coverage limits up to date. Would you like to review the coverage limits you have chosen on your current home, secondary dwellings, or detached structures? * This field is required.

YESNO

13

Have you done any remodeling, additions, or updates to your home, secondary dwellings, or detached structures? -- Examples include but are not limited to: replacing or upgrading roofs, HVAC systems, plumbing, electrical, appliances, finishing basements or attics, adding additions or structures, etc.* This field is required.

YESNO

14

Does anyone operate a business from your home, secondary dwellings, or detached structures, that earns more than $2,000 a year or has more than $1,500 in business property? -- Examples include but are not limited to: daycare, teaching music or dance, selling cosmetics, mowing lawns, manufacturing, home office, etc. * This field is required.

YESNO

15

Do you provide any short-term or temporary rentals of your home, secondary dwellings, detached structures, or land, including informal rental arrangements? --Examples include but are not limited to: Airbnb, VRBO, Swimply, Sniffspot, Hipcamp, Tentrr, Nieghbor, Stow It, or privately renting to friends or neighbors, or similar activities.* This field is required.

YESNO

16

Do you provide any longer-term property rental or lease arrangements that are not already insured? -- Examples include but are not limited to: rental or leasing of a room, a secondary dwelling, rental dwelling, detached structures, or land to others.* This field is required.

YESNO

17

Do you own any properties (such as a second home, rental, vacant home, or vacant land) that are not currently insured and need a quote?* This field is required.

YESNO

18

Do you currently engage in any farming or ranching activities that are not insured and need coverage quoted? * This field is required.

YESNO

19

Even if not actively engaged in farming or ranching, do you own any farm animals? -- Examples include but are not limited to: Livestock, Horses, Llamas, 4H animals, etc.* This field is required.

YESNO

20

Are you a member of a Board (paid or voluntary) and does the organization carry Directors & Officers (D&O) coverage, to protect board members? -- Examples include but are not limited to: HOAs, condo associations, non-profits, PTA or PTO, school booster clubs, youth sports leagues, religious boards, fraternal clubs, hobby clubs, etc.

YESNO

21

Many homeowners policies limit or exclude liability arising out of the use of aircraft, including drones. Do you, or any household member, own or use any drones or unmanned aerial vehicles? --This includes recreational or hobby drones, or other aircraft.

YESNO

22

Do you have any dependent children, age 21 or older, who are attending college or living outside your home?* This field is required.

YESNO

23

Flood and earthquake coverage are not included in standard homeowners policies. Would you like a quote for either of these coverages?* This field is required.

YESNO

24

Most homeowners policies provide limited coverage for items such as firearms, jewelry, furs, business property, collectibles, antiques, fine arts, and precious metals. Would you like to increase these limits or schedule specific items for additional coverage?

YESNO

25

Some insurers offer identity fraud expense coverage. Would you like a quote for this coverage?* This field is required.

YESNO

26

Many carriers offer optional coverages not included in standard homeowners policies. Would you like a quote for any additional coverages not already addressed in this questionnaire? -- Examples include but are not limited to: Equipment Breakdown (mechanical systems), Water/Sewer Backup, Water Seepage, etc.* This field is required.

YESNO

27

Home Insurance CommentsPlease provide details for any "Yes" answers.

28

Do you own any recreational vehicles that are not currently insured and need coverage quoted? -- Examples include but are not limited to: boats, jet skis, motorcycles, trikes, e-bikes, dirt bikes, snowmobiles, motorhomes, golf carts, aircraft, etc.* This field is required.

YESNO

29

Would you like a quote for an Excess Liability policy (also known as a Personal Umbrella), which provides additional liability limits over your auto and homeowners policies?* This field is required.

YESNO

30

If you already have an Excess Liability or Personal Umbrella policy, would you like to review or increase your coverage limit?

YESNO

31

Would you like to speak with a team member about a Life, Health, Disability, or Medicare Supplement insurance options?* This field is required.

YESNO

32

Have there been any changes in your life or circumstances that are not already addressed and may affect your insurance coverage?* This field is required.

YESNO

33

Other Insurance CommentsPlease provide details for any "Yes" answers.

34

Signature

Clear