REMARKET REQUEST
Epic Code
*
Full Name
*
First Name
Last Name
Reason for Remarket
Renewal Date
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Homeowner Insurance Questions
1. Have you renovated or added a pool, spa, sauna or trampoline?
Yes
No
If yes, please describe.
2. Year of roof update, full or partial?
3. Have you purchased any new high value contents such as jewelry, artwork, fur, guns?
Yes
No
If yes, provide item description and value.
4. Have you installed a secondary heating system (example: woodstove)?*
Yes
No
5. Are there any business activities on premise (customer/employees/equipment)?
Yes
No
If yes, provide brief description.
6. Do you own a dog, exotic animal or have any farm animals on your premises? If yes, please include breed and bite history if any.
Yes
No
Breed and bite history
7. Do you own real estate other than your primary home?
Yes
No
Describe Property
8. Have you purchased any other sport vehicles (example: ATV, golf cart, camper, trailer, boat, etc.)?
Yes
No
If yes, list vehicles; year, make, model and value.
9. Have you had a monitored alarm system installed?
Yes
No
Auto Questions
1. Do you have any new licensed household members/children that are not listed as drivers on your current policy?
Yes
No
If yes, enter name, DOB, DL# and relationship
2. Are any of the vehicles on the policy used for any type of delivery service or ride sharing service like Uber or Lyft?
Yes
No
If yes, explain
Additional Notes
Form Submitted By
Your Name
SUBMIT
Should be Empty: