Life Changes Simple Survey

Date

Name

First NameLast Name

Preferred Email

example@example.com

Preferred Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Has your mailing address changed?

Correct Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you had any Life Changes since your last renewal?

Please let us know about life changes such as:

● New child
● Employment change
● New driver/ teen driver in the household
● Acquired or sold any vehicles (including RV, trailer, boat, motorcycle)
● Purchased or sold real estate
● Created a living trust

Tell us about your Life Changes

Has your Marital Status changed?

Please provide details

Own a business?

Name of business

What type of business do you own?

Interested in a Business Insurance Quote?

Having commercial insurance with our agency can sometimes provide discounts for both your personal insurance and business insurance.

Have you earned a degree or certification since your last renewal?

Higher education can potentially add up to additional savings. This includes college, military MOS training, and vocational certifications (cosmetology school, journeyman/apprenticeship program, trucking school, etc).

Type of degree or certification

Have your driving habits changed?

If you were commuting to work, but now work from home you could receive an additional discount.

Are you using your car for work (Uber driver, contractor going from site to site, realtor, etc) and/or are you advertising for your business on your vehicle?

These factors could have extra exposure and coverage concerns that we would want to advise you on to ensure you are properly protected.

Tell us about the changes in your driving habit

Would you like to save up to 40% by bundling your Home and Auto?

Bundling your Home & Auto can save you up to 40%. Simply select Yes to see how much money you can save.

Would you like a quote for Flood Insurance

Bundling your Home & Auto can save you up to 40%. Simply select Yes to see how much money you can save.

Have you completed any Home Improvements to your home

New roof, kitchen/bathroom upgrades, additional square footage, etc...

When was the last time you replaced your roof

Tell us about your Home Improvements

Do you have any special Personal Property or Items of High Value

Items such as jewelry, weapons, fine arts, fur coats, musical equipment, fine china, high-end bicycles may require special coverage to protect you against theft, breakage or mysterious disappearance.

Would you like a quote to provide coverage for special personal property?

Most homeowner policies limit coverage on these categories to $1,500 - $2,500 TOTAL per category.

List the items and their approximate value

Would you like a quote for an Umbrella Policy (Additional Personal Liability Coverage)

Personal Umbrella Liability Coverage is sometimes referred to as lawsuit coverage and helps to protect your assets in the event that someone tries to sue you for bodily injury, property damage and even personal injury.

$1M of Personal Umbrella protection can cost as little as $250/year.

Our agency HIGHLY RECOMMENDS that you consider this important and inexpensive coverage.

Are you interested in receiving an affordable Life Insurance quote

Do you have Life Insurance outside of your employer?

Many times this Life Insurance does not follow you if you leave the job.

This small and simple action can leave a lasting legacy and financial protection for your family when you pass away.

Additional Items to Insure

Great! Let us know what we can quote for you

Is there anything else we should be aware of as your renewal approaches

File Upload

Thank you for your time in providing us with this update! We are grateful for your business and for trusting us with your insurance needs.

Have a great day!