Life Changes Simple Survey

1
Date
Date
Month
Day
Year
2
Name* This field is required.
First Name
Last Name
3
Preferred Email* This field is required.
example@example.com
Email Verified
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4
Preferred Phone Number* This field is required.
Please enter a valid phone number.
5
Has your mailing address changed?* This field is required.
Yes
No
6
Correct Mailing Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Have you had any Life Changes since your last renewal?* This field is required.
Yes
No
8
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
9
Tell us about your Life Changes* This field is required.
10
Has your Marital Status changed?* This field is required.
Yes
No
11
Please provide details* This field is required.
12
Own a business?* This field is required.
Yes
No
13
What type of business do you own?* This field is required.
14
Interested in a Business Insurance Quote?* This field is required.
Yes
No
15
Name of Business
16
Having commercial insurance with our agency can sometimes provide discounts for both your personal insurance and business insurance.
17
Have you earned a degree or certification since your last renewal?* This field is required.
Yes
No
18
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).
19
Type of degree or certification* This field is required.
20
Have your driving habits changed?* This field is required.
Yes
No
21
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.
22
Tell us about the changes in your driving habit* This field is required.
23
Would you like to save up to 40% by bundling your Home and Auto?* This field is required.
Yes
No
I already bundled
24
Bundling your Home & Auto can save you up to 40%. Simply select Yes to see how much money you can save.
25
Would you like a quote for Flood Insurance* This field is required.
Yes
No
I already have flood insurance
26
Bundling your Home & Auto can save you up to 40%. Simply select Yes to see how much money you can save.
27
Have you completed any Home Improvements to your home* This field is required.
Yes
No
N/A
28
New roof, kitchen/bathroom upgrades, additional square footage, etc...
29
When was the last time you replaced your roof* This field is required.
30
Tell us about your Home Improvements* This field is required.
31
Do you have any special Personal Property or Items of High Value* This field is required.
Yes
No
I already have a Special Personal Property Policy
32
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.
33
List the items and their approximate value* This field is required.
34
Would you like a quote for an Umbrella Policy (Additional Personal Liability Coverage)* This field is required.
Yes
No
I already have one
35
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.
36
Are you interested in receiving an affordable Life Insurance quote* This field is required.
Yes
No
I already have one
37
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.
38
Additional Items to Insure* This field is required.
RV
Boat/Jet Ski
Motorcycle
ATV
Rental Property
Vacation Home
Other
None
39
Great! Let us know what we can quote for you* This field is required.
40
Is there anything else we should be aware of as your renewal approaches
41
File Upload
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42
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!
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