Norgaard Agency Inc_23-0338-00

Annual Review Form

Please fill out this brief form to help us ensure proper coverages are in place.
Insured(s) Names*
Phone Number(s)*
If we have questions regarding your policies, can we text you?*

Yes, please send me an opt-in textNoAlready Enrolled
Email Address(s)
Preferred Communication Method*

CallTextEmailIn-person at the office
Please elaborate on any recent life updates.
Change in marital status, jobs, living arrangements,commute miles, etc.
Homeowners Information
People in the Household*
Please provide the full name and birth dates for all household members
Occupation & Employers*
Please provide the occupation and employer information for each applicable household member
Have you any new toys?*
If you have purchased a new toy, please provide the unit information below
Year, Make, Model, Motor Size, Anticipated Use, Value
Have you made any improvements to your home in the last five years?*
Ex: Security system, updated roof, finished basement, trampoline, pool, garages, updated heating, electrical, or plumbing.
Type of roof and year it was last updated:
Type of electrical and year it was last updated:
Year your plumbing was updated, and do you have a sump pump?:
Type of heat and year last updated:
Does the home have any wood or pellet heat?*

YesNo
If yes, please elaborate below:
Does your home have a basement?
Please detail if your basement is finished, and if so, what percentage. Also indicate if you have a sump pump and, if so, how it is powered.
Please select all of the following that are applicable to your home

Security SystemFire alarmSmoke DetectorNon-smoking residenceGated EntryGeneratorSensor for leaks
Do you own investment properties?*

NoYes, not currently insuredYes, separately insured
Do you ever rent out your home?*

NoYes
Do you own any businesses?*

YesNo
If you run a business out of your home, please provide more information
Type of business, customer foot traffic, etc.
Who is your current mortgagee company?*
If there is no loan on the home, please type "NONE"
Preferred Home Deductible*

$1000$1500$2000$2500
How do you prefer to pay*

Full PayMonthly Direct BillMonthly EFTEscrowed
Please provide an estimated value of what you believe it would cost to rebuild your home*
Ex: Coverage A
Do you have any animals on the premise? If so,please indicate how many, the type, and breed for each animal.
Trampoline on the premise?

YesNo
Auto Information
Please confirm the automobiles, trucks, and trailers on your policy*
Provide the year, make, and model for existing autos. For any new vehicles, please include the VIN.
Please list all the drivers on the policy and their vehicle assignment*
Please list any vehicles used to commute and the miles one way
Any new traffic violations, at-fault accidents, or claims?
Please list for all drivers on the policy and include incident date
Please list lien holders for each vehicle, if applicable
New youthful driver?

NoYes
Are any policy drivers participating in delivery or ride share (Ex: Uber, Uber Eats, Lyft, Door Dash, Dominos Delivery, etc.)*

NoYes
Do any drivers have a company-furnished vehicle?*

No, an employer does not provide any driver on the policy with a vehicleYes, an employer provides a driver on the policy with a vehicle
Any vehicles kept away at school?*

YesNo
Where are vehicles stored?*

GaragedOn StreetDrivewayMixture
Preferred Auto Deductible*

$250$500$1000$1500
Thank you for choosing Norgaard Agency!

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Annual Review Form

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