Annual Client Review
Your Name
*
First Name
Last Name
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Rate your experience:
How would you rate your experience with our agency?
*
Please Select
Beyond Expectations
Excellent
Good
Poor
How could we improve your experience with our agency?
Please be as specific as possible with your suggestions. We would like very much to improve our process/experience for all of our customers!
About you and your family
Have you had a martial status change?
*
Yes
No
Any new pets in the house?
*
Yes
No
Great!! Pleas tell us about your new pet:
Name / type of animal / favorite treat
Any new family members added to the family?
*
Yes
No
Exciting!! Please tell us about your new addition :
Name / relation
Homeowners Information
What year was your roof replaced?
*
If you don't own a home type NONE
Have there been any significant improvements to your home in the last 12 months?
*
Yes
No
Do not own a home
Please list the improvements made to the home.:
Please include a short description and the amount paid for the improvement(s)
Have you purchased any jewelry, furs, art, cameras or collectibles in the last 12 months?
*
Yes
No
Please provide a list of items and their purchase amounts or estimated values
Item description / Value
Have you purchased a secondary home, rental property, farm or vacant land in the last 12 months?
*
Yes
No
Please include the address and purchase price of your new property below
Did you recently start a in-home business?
*
Yes
No
What type of business did you start?
Please include a website or FB page for your new business:
Auto Information
Do you need to add a vehicle to your policy?
*
Yes
No
Please provide the new vehicle info below:
Year / Make / Model
Have you been given access to an employer provided vehicle?
*
Yes
No
Any new drivers in the household?
*
Yes
No
Please list all new drivers info below:
Name / Date of Birth / Drivers License Number
Do you have any children attending college?
*
Yes
No
Do you have any children under the age of 25 that currently have a GPA of 3.0 or higher?
*
Yes
No
General Information
Are you currently on any non-profit board of directors?
*
Yes
No
What are the board names and what position/title do you hold?
In this last 12 months, have you started a new job? Ben promoted? or Any change of income/net worth?
*
Yes
No
have you hired any full-time help? (landscaping, nanny, cleaning, etc.)
*
Yes
No
What position did you hire and how many hours a week to they work at your residence?
Submit
Should be Empty: