Annual Review Form
Please fill out this brief form to help us ensure proper coverages are in place.
Insured(s) Names
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Phone Number(s)
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If we have questions regarding your policies, can we text you?
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Yes, please send me an opt-in text
No
Already Enrolled
Email Address(s)
Preferred Communication Method
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Call
Text
Email
In-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
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Please provide the full name and birth dates for all household members
Occupation & Employers
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Please provide the occupation and employer information for each applicable household member
Have you any new toys?
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Please Select
NONE
Boat
RV
Camper
ATV
Motorcycle
Golf Cart
Other
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?
*
Yes
No
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 System
Fire alarm
Smoke Detector
Non-smoking residence
Gated Entry
Generator
Sensor for leaks
Do you own investment properties?
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No
Yes, not currently insured
Yes, separately insured
Do you ever rent out your home?
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No
Yes
Do you own any businesses?
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Yes
No
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?
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If there is no loan on the home, please type "NONE"
Preferred Home Deductible
*
$1000
$1500
$2000
$2500
How do you prefer to pay
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Full Pay
Monthly Direct Bill
Monthly EFT
Escrowed
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?
Yes
No
Auto Information
Please confirm the automobiles, trucks, and trailers on your policy
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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
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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?
No
Yes
Are any policy drivers participating in delivery or ride share (Ex: Uber, Uber Eats, Lyft, Door Dash, Dominos Delivery, etc.)
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No
Yes
Do any drivers have a company-furnished vehicle?
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No, an employer does not provide any driver on the policy with a vehicle
Yes, an employer provides a driver on the policy with a vehicle
Any vehicles kept away at school?
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Yes
No
Where are vehicles stored?
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Garaged
On Street
Driveway
Mixture
Preferred Auto Deductible
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$250
$500
$1000
$1500
Thank you for choosing Norgaard Agency!
Thank you for completing the Annual Review Form. We will be in touch!
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