Personal Insurance Review Form

Name

First NameLast Name

Email

example@example.com

Best Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

1. Let’s say you were driving to work tomorrow, had an accident, you were at fault, and there was 300,000.00 in damages- would you want your policy to pay all damages?

2. How many licensed drivers are in your household?

3. In the next 1 - 2 years will you have any new drivers?

Make sure to discuss EXCLUSIONS and other limitations for youthful drivers and other household residents.

4. Please list current occupations of drivers below, as many companies now offer certain professional discounts:

1. Have you made any improvements or additions to your home over the past couple years?

If YES above, please provide details:

2. Have you added a burglar alarm or other security devices?

If YES above, please provide details:

3. Do you have jewelry you would want replaced if it were lost on vacation?

If YES above, please provide details:

4. Have you made any major purchases during the past year?

If YES above, please provide details:

5. Do you have an inventory of all your household possessions?

6. Do you want damages from flood and/or earthquake covered by your policy?

7. Do you still have mortgage(s) on your home?

8. In the event one of the household breadwinners passed away, have you thought about life insurance protection?

9. Let's say you were involved in an accident in your car, or someone hurt themselves on your property, and you were sued for $1,000,000 - where would you want the money to come from?

10. Do you have any vacation homes, rental properties, recreational vehicles or motorcycles?

If YES to any of the above, would you like us to provide a free quote?

11. If you have had any claims in the past 5 years, were they all handled to your complete satisfaction?

12. Is there anything additional you would like us to know about that might affect your insurance program?

Please be advised that no updates or changes can be made to any of your insurance policies until you authorize one of our agents to process any policy changes.

Thank you, for your time!

Your Personal Insurance Review

AUTO INSURANCE PROTECTION

HOMEOWNERS INSURANCE PROTECTION