Eagle Rock Insurance_11-0080-00_Home Renewal Review Form

PERSONAL INFORMATION:

Name

First NameLast Name

Email

example@example.com

Primary Phone Number

Area CodePhone Number

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Address

Street Address

Street Address Line 2

CityState / 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?

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?

Describe

Do you have any alarms installed in your home?

If so, what type?

Do you have children away at college?

Any remodeling, additions, alteration to your home in the past 24 months?

If so, what type?

Is your basement finished?

If yes, what percentage?

Do you own a business or plan to start one?

Do you operate an office or studio in your home?

If so, do clients come into your home to make purchases?

Do you have any domestic employees?

Do you rent any part of your home and/or separate structures?

Any residents in your household who are not related to you?

Do you have in-home day care?

Do you have a dog, cat or other pet?

If so, what breed?

Any bite history?

Do you use a wood-burning stove?

Do you have a swimming pool?

If so, is it fenced?

Diving Board?

Do you own rental/investment property, second residence/vacation home (i.e. condo, cabin, or trailer)?

Do you belong to a Homeowners Association?

Do we carry your auto insurance?

If not, can we quote you?

Interested in:

FINANCIAL:

Would you like a complimentary retirement cash flow analysis?

Would you like a complimentary Social Security benefits analysis?

Would you like a complimentary review of the tax impact of your current retirement income strategy?

MISCELLANEOUS:

Do you own any of the following recreational vehicles?

If others, please list:

OPTIONAL COVERAGES:

Are you interested in:

Comments/Notes:

VERIFICATION CODE:

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