Home Renewal Review Form
Eagle Rock Insurance
PERSONAL INFORMATION:
Name
First Name
Last Name
Email
example@example.com
Primary Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does your Policy Declarations Page correctly list: Legal names that appear on the deed? Mailing and property address? Mortgage Company name, address and loan number?
Yes
No
Do you have particular items to schedule? Collectible, antiques, fine art, stamps, coins, baseball cards, jewelry, furs, firearms, costly sporting equipment, cameras, tools, equipment or instruments?
Yes
No
Describe
Do you have any alarms installed in your home?
Yes
No
If so, what type?
Do you have children away at college?
Yes
No
Any remodeling, additions, alteration to your home in the past 24 months?
Yes
No
If so, what type?
Is your basement finished?
Yes
No
If yes, what percentage?
Do you own a business or plan to start one?
Yes
No
Do you operate an office or studio in your home?
Yes
No
If so, do clients come into your home to make purchases?
Yes
No
Do you have any domestic employees?
Yes
No
Do you rent any part of your home and/or separate structures?
Yes
No
Any residents in your household who are not related to you?
Yes
No
Do you have in-home day care?
Yes
No
Do you have a dog, cat or other pet?
Yes
No
If so, what breed?
Any bite history?
Yes
No
Do you use a wood-burning stove?
Yes
No
Do you have a swimming pool?
Yes
No
If so, is it fenced?
Yes
No
Diving Board?
Yes
No
Do you own rental/investment property, second residence/vacation home (i.e. condo, cabin, or trailer)?
Yes
No
Do you belong to a Homeowners Association?
Yes
No
Do we carry your auto insurance?
Yes
No
If not, can we quote you?
Yes
No
Interested in:
Water back up or quote to increase current coverage
Identity Theft Coverage
Flood Insurance
FINANCIAL:
Would you like a complimentary retirement cash flow analysis?
Yes
No
Would you like a complimentary Social Security benefits analysis?
Yes
No
Would you like a complimentary review of the tax impact of your current retirement income strategy?
Yes
No
MISCELLANEOUS:
Do you own any of the following recreational vehicles?
Boat/Jet Ski
Motorcycle
Golf Cart
All Terrain Vehicles
Motor-home
Camper
Moped
Snowmobile
Other
If others, please list:
OPTIONAL COVERAGES:
Are you interested in:
Identity Theft
Flood Insurance
Umbrella Policy
Life Insurance
Disability Insurance
Comments/Notes:
VERIFICATION CODE:
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