Norgaard Agency Inc_23-0338-00

Annual Review Form

Please fill out this brief form to help us ensure proper coverages are in place.
How did you hear of Norgaard Agency?
Insured(s) Names
Phone Number(s)
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Email Address(s)
Preferred Communication Method
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?
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
Do you own investment properties?
Do you ever rent out your home?
Do you own any businesses?
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
How do you prefer to pay
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?
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?
Are any policy drivers participating in delivery or ride share (Ex: Uber, Uber Eats, Lyft, Door Dash, Dominos Delivery, etc.)
Do any drivers have a company-furnished vehicle?
Any vehicles kept away at school?
Where are vehicles stored?
Preferred Auto Deductible
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Annual Review Form

Homeowners Information

Auto Information

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