Let's get started!
We know, we know. Surveys are annoying, but this one is critical in allowing our team to make sure you're properly protected! On average, this form takes 7 minutes.
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What's your full name?
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First Name
Last Name
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Let's make sure we have the correct cell phone number on file for you.
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Please enter a valid phone number.
Format: (000) 000-0000.
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Let's make sure we have the best email on file for you.
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example@example.com
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Let's make sure we have the best mailing address on file for you.
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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When it comes to insurance, which of these is most important to you?
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Price is my main concern. I need budget-friendly options.
Coverage is my main concern. I want to see all potential coverage offerings.
A balance between price and coverage - price is a factor but not the only factor.
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What insurance policies do you have now (even if they aren't with our agency)?
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Auto
Home (you own your home)
Renters (you rent your home)
Landlords (you own a property that you rent to others)
Motorcycle / ATV / Camper / Trailer / Boat / Other Toy
Commercial / Business Policy
Umbrella (excess liability)
Jewelry Policy
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Over the next few questions, we're going to be focusing on your auto insurance.
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Is there anyone over the age of 15 that lives in your home and is not currently on your policy (even if they aren't licensed, aren't driving, or have their own policies)?
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Yes, there is someone over 15 in my home and not on my policy.
No, everyone over 15 is on my policy.
What is your relationship to and name of the other driver(s) in your household?
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Some carriers offer discounts based on certain occupations. Please list the occupations for all drivers. Also, please let us know if anyone has a Commercial Drivers License - many carriers offer a discount for CDL holders.
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Examples: Stephanie - Student, Mark - Military, James - Firefighter
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Does anyone is your household drive for any rideshare or meal delivery services (Uber, Lyft, DoorDash, pizza delivery, etc)?
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Yes
No
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Do you own any additional vehicles that we are not currently insuring?
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Yes
No
Can you give us a little feedback on why we don't insure them (company car, insured elsewhere, etc)?
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Liability coverage is what protects you from lawsuits when you cause bodily injury or property damage - like an auto accident.
Would you be interested in increasing your current liability coverage?
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Yes
No
Maybe - I'd like to see how it affects my premium.
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Over the next few questions, we're going to be discussing your homeowners insurance.
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Home insurance policies have limited coverage for certain items in your home. Do you have any of these you would like to discuss to make sure they are adequately protected?
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Collectibles
Silverware
Artwork
Musical Instruments
Firearms
None of the above
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Would you be interested in raising your home insurance deductible if it saved you money?
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Yes
No
Maybe - I'd like to see how it affects my premium.
We'll explore that for you. What deductible options interest you the most? You can select more than one.
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$2,500
$5,000
$10,000
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We currently have your home insured for the estimated replacement cost.
Keep in mind, this is to rebuild your home. It does not reflect your home's market value, personal property, detached structures, etc. Those may be covered separately.
What are your thoughts on your current replacement cost?
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Seems about right
Might be too low
I don't know my current replacement cost - please sent it to me.
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What year did your roof last have repair work done to it?
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This is a critical piece of information. Please give us the "best of your knowledge" year your roof was worked on.
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Please select any of the following that you have on your property. We will double check these items to make sure there are no coverage gaps for these items.
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Pool
Trampoline
Farm Animals
Exotic Animals
Animal(s) with a bite history
In-home daycare
Any kind of business on the property (accounting, lawyer, work from home office, etc)
None of the above
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The following are perils that home insurance does NOT typically cover. If you're interested in getting a quote on any of these, please check them below.
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Earthquake
Flood / Rising Water
No, I'm not interested in either.
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Is any of your home occupied by a tenant?
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No
Yes, short term rental (AirBnB, VRBO, etc)
Yes, long term rental (typically 6+ month lease terms)
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Do you have any pets?
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Yes
No
Awesome! We are "pet people" too! What pets do you have? Please include their name(s) and breed(s).
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Do you own any "toys" such as RVs, travel trailers, boats, ATVs, golf carts, or motorcycles that we don't currently insure?
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Yes
No
Nice! What do you have?
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Some home policies will extend coverage to these items. We will check if any policies you have now do that.
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Do you own any jewelry that would cost more than $1,000 to replace?
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Yes, I do.
No, I do not.
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How would you rate the service you have received from us in the past year?
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1
2
3
4
5
This is for our agency - not your carrier.
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Since we are your insurance agent, we're often contacted after someone passes about the existence of life insurance policies. Who is your current life insurance with?
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I don't have any.
I have coverage through work.
Other
Would you be interested in speaking with Faith, our life & health insurance expert?
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Yes, please!
No, thank you.
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This form is designed for your convenience. Would you like to schedule a meeting to discuss your policy?
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Yes, I'd like to schedule an appointment.
No, thank you. I'm happy with my renewal and don't wish to discuss it.
If you do not schedule a meeting, we will not reach out about your renewal, including requoting it.
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Anything you'd like to add before we submit? You can list questions, comments, concerns, etc
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