Insurance Service Center DePere

Review Checklist
Client Name:*

First NameLast Name
Phone Number:

Area CodePhone Number
Please check any items that you own, and indicate how many if applicable.

* Be sure to include items insured elsewhere, out of state, etc. *

VEHICLES:

Rows	Do NOT Own	1	2	3	4	5	6	More than 6
Private Passenger Vehicle
Collector Cars / Antique Cars
Golf Cart
Motorcycle
Moped
Any vehicles with salvage titles
Motorhomes / Campers

* If you indicated you have a motorhome/camper, are they permanently parked?

YesNo
* If you indicated you have a motorhome/camper, do you have an awning or other accessories?

YesNo
If yes, please explain:

RECREATIONAL VEHICLES / EQUIPMENT

Rows	Do NOT Own	1	2	3	4	5	6	More than 6
Boat
ATV / UTV
Dirt Bike
Snowmobile
Kids Toys (Barbie Jeep, Go Carts....)
Jet Ski
Tractor / Skid steer / Equipment
Trailer (utility, cycle, ATV, boat, snowmobile, etc.)

BUILDINGS / LAND
(Please check any items that you own.)

Home (List # of acres if greater than 1 acre below.)Garage (detached from home)ShedCondoHunting Shack / Hunting CabinRental PropertyBarn / Silo / Grainery / Chicken Coop / etc.CottageGazebo / Pergolas
* If you indicated you own a home, list # of acres if greater than 1 acre:
Land (including farm, hunting, vacant, etc.)

YesNo
* If you indicated you have land, how many acres?
* Does this land have any improvements (such as fences, outhouse, shed, shack, deer stand, etc.)?

YesNo
* If yes, please explain:
* Is any of the land rented to others?

YesNo
* If yes, please explain:
MISCELLANEOUS
(Please check any items that you own.)

A BusinessTrampolineSwimming Pool / Hot TubRetaining Walls / FencesWoodstove, Wood Burner, Pellet Stove, Fireplace insertAlarm System in Home
WOULD YOU LIKE COVERAGE FOR...
(Please check any of the optional coverages you are interested in.)

Hearing AidsFine Art / Antiques / FursStamps, Coins or Baseball Card CollectionValuable JewelryValuable Sporting EquipmentValuable Fire ArmsValuable Cameras or Photography EquipmentHigh Value - Computers, Laptops, TabletsComputers, Laptops, Tablets used in businessHigh Value Medical Items (prosthesis, wheel chairs, etc.)Lawnmower valued over $10,000.00Cash over $200.00Tools, Equipment or Instruments used in your trade or profession
ADDITIONAL QUESTIONS
Do you own any dogs?

YesNo
If yes, what breed?
Bite History?
Do you own any other animals?

YesNo
If yes, please describe:
ARE YOU INTERESTED IN...
Life Insurance (for you or your family)Retirement Accounts / IRA / Roth IRA / 401K Roll Over*Health Insurance / Medicare ProductsDisability InsuranceDental InsuranceFinancial Analysis*Long Term Care InsuranceBurial Funeral TrustCollege Planning*Mortgage Insurance
**Coverage subject to policy limitations and payable in the event of qualified claims. Subject to underwriting approval.

*Securities and advisory services offered through Packerland Brokerage Services, Inc., an unaffiliated entity, Member FINRA & SIPC

I have personally reviewed the answers above. I understand that this checklist is not meant to imply in any manner that these are the ONLY items that may be of concern to me. I understand it is my responsibility to advise Insurance Service Center of any special circumstances or insurance needs I may have, or as my situation changes.
Client Signature:
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Review Checklist