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.

YesNo

Correct Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YesNo

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*

YesNo

Please provide details*

YesNo

Name of business*

What type of business do you own?*

YesNo

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

YesNo

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*

YesNo

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*

YesNoI already bundled

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

YesNoI already have flood insurance

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

YesNoN/A

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

When was the last time you replaced your roof*

Tell us about your Home Improvements*

YesNoI already have a Special Personal Property Policy

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*

YesNoI already have one

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.

YesNoI already have one

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.

Great! Let us know what we can quote for you*

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

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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!