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. Are you interested in increasing your automobile liability limits? * This field is required.

YESNO

5

Do you have any vehicles in your household that we do not presently insure that you would like coverage quoted for?* This field is required.

YESNO

6

Are there any drivers living in your household not presently listed on your automobile policy?* This field is required.

YESNO

7

If you own a pickup or van, does it contain any customized equipment you would like coverage quoted for?* This field is required.

YESNO

8

Do you own a pickup camper unit, camper shell, or any type of trailer you would like coverage quoted for?* This field is required.

YESNO

9

Do you use your or any other vehicle at your house as an UBER or similar service?* This field is required.

YESNO

10

Auto CommentsPlease provide details for any "Yes" answers.

11

Building costs have increased over the last few years and it is important to keep your building values up to date. Would you like to review the adequacy of the current dwelling or detached structures amount you have chosen? * This field is required.

YESNO

12

Have you remodeled your home, finished your basement, completed a recent addition, or added a structure to your premises? If yes, please contact us to discuss the changes in insurance coverage you may need. * This field is required.

YESNO

13

Does any resident of your home operate a business from your home which earns more than $2000 a year? (examples include daycare, teaching piano lessons, selling cosmetics, mowing lawns, having a home office, etc.) * This field is required.

YESNO

14

Do you own a second home, properties rented to others, vacant or unoccupied home or vacant land that this not currently on your policy that you would like coverage quoted for?* This field is required.

YESNO

15

Are you presently engaged in any form of farming or ranching not currently insured that you would like coverage quoted for? * This field is required.

YESNO

16

Flood and earthquakes are not included in your homeowner policy. Are you interested in a quote for either coverage?* This field is required.

YESNO

17

Most homeowners’ policies provide limited coverage to guns, jewelry, furs, business property, collectibles, antiques, fine arts, precious metals, etc. Refer to your policy for details. Are you interested in increasing these limits or scheduling items for more coverage?

YESNO

18

If not already listed on your home policy, would you like a quote for Identity Fraud, which provides coverage for expenses you incur as a direct result of identity fraud?* This field is required.

YESNO

19

Do you have any dependent children aged 21 or older going to college or residing outside your home?* This field is required.

YESNO

20

If not already listed on your home policy, are you interested in equipment breakdown (mechanical systems) coverage? (This coverage is subject to your homeowner deductible)* This field is required.

YESNO

21

Do you rent your home or other dwellings on Airbnb or a similar site?* This field is required.

YESNO

22

Are you a member of a board and does it have Directors & Officers coverage, protecting the members?

YESNO

23

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

24

Do you own any recreational vehicles not currently insured that you want coverage quoted for? (including boats, jet skis, motorcycles, e-bikes, dirt bikes, snowmobiles, motorhomes, golf carts, aircraft, etc.)* This field is required.

YESNO

25

Do you use a drone?

YESNO

26

Are you interested in an Excess Liability policy, commonly referred to as an Umbrella. This policy extends coverage over your automobile and homeowners liability to provide limits up to $1 million or more.* This field is required.

YESNO

27

Are you interested in an Excess Liability policy, commonly referred to as an Umbrella. This policy extends coverage over your automobile and homeowners liability to provide limits up to $1 million or more.

Yes

I currently have one.

No

28

If you already have an Excess Liability policy, are you interested in increasing your liability limit?

YESNO

29

We also have a team that provides Health, Life Insurance, and Annuities. Are you interested in speaking to a team member about a Life, Health, Disability, or Medicare Supplement policy?* This field is required.

YESNO

30

Has anything, not already covered, changed in your life that may affect the insurance coverage? * This field is required.

YESNO

31

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

32

Signature

Clear