Renewal Worksheet - Personal Coverage

Please provide your name*

First NameLast Name

Please provide your email address*

example@example.com

Let's walk through a quick check-Up. It will take less than a minute, but it will help us to be sure you are receiving the credits, discounts and coverage features you care most about.

Some of the features may be very important to you, others, not so much. After you finish the check-up, please hit the SUBMIT button at the bottom and we'll send you a copy for your records.

If you've asked us to adjust your coverage, and if you don't hear back from us within a day, please alert us.

By the way, you can see explanations about these coverage types, CLICK HERE.

A response is required on every line*

	I don't care about this	I care about this
Fire damage to your home's structure
Fire or Liability Protection on other properties that you own
Theft and vandalism to your personal belongings in your home
Coverage for Jewelry, Art, Antiques, Guns or other collections of value
Earthquake & Flood Damage
Auto Insurance Coverage
RV/Aircraft/Motorcycle/Boat
Umbrella or Excess Liability Protection including Excess Uninsured Motorists
Workers Compensation for Domestic Employees
Employment Practices Liability for Domestic Employees
Individual Health Insurance or Medicare Supplement Coverage
Individual Life Insurance Protection
Coverage for a home based business

Would you like to discuss any other questions with us?*

NoYes

If you've marked YES to the prior answer, briefly describe what you've got on your mind so that when we speak, we will be reminded to discuss those with you

Do you periodically review your insurance for its adequacy and do you ask your insurance representative to make adjustments when you want them?*

YesNo

Will any of your vehicles be used for ridesharing services such as Uber or Lyft?*

NoYes

Will any of your properties be enrolled for use as Airbnb or VRBO?*

NoYes

Any time you acquire or dispose of assets, make a purchase or lease something, or re-finance something, you should have a conversation with your insurance broker, your CPA and maybe even your attorney.

Please provide your cell phone number*

Area CodePhone Number

Who do you mostly work with here at UWIB?*

Alicia Phone

Veronica Phone

HIDDEN - PHONE

Do you prefer Texting or email?*

EmailTextingEither is fine

Want to read the fine print?*

NoYes

This document contains a few general descriptions of just a handful of coverage types. Although the ons listed are popular and common, they don't include all coverages, all features, all exclusions, or any of the conditions that probably would apply in a specific case. In fact, coverages, features, and credits vary by state and may not be available to every policyholder. United Western Insurance Brokers strives to be very open and transparent with all policyholders. Policyholders with questions are encouraged to reach out to the agency’s service team members with questions that they have regarding their own insurance and risk management needs.

Your name in this field signifies that you understand you may revise, adjust or modify your responses at any time by contacting your UWIB service team.*

(Please Type Your Initials Here)

After you hit the SUBMIT button, we'll send you a copy of this worksheet for your records. Thank You!

Please click the SUBMIT button now

Date

Dana Email

example@example.com

Personal Coverage Check-Up