| This form is to be used by our clients. Provides a quick and convenient way for us to learn about changes in your life which may require modifications in your insurance program. |
Are you a homeowner?
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Are you renting?
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Are you concerned about the amount of coverage on your home or contents?
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Do you have a renter or roommate?
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Do you have valuable jewelry or furs which you may want covered?
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Do you have collectibles: antiques, fine arts, stamps, or coins, etc which you may want insured?
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Do you have costly sporting equipment or firearms which you may want covered?
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Do you have valuable photography or portable electronics which you may want covered?
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Do you operate a business from your home?
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If you operate a business from your home, do clients come to you?
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If you operate a business out of your home, do you keep inventory at your home?
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Do you own professional tools or equipment that is use in your job?
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Do you operate a child day care out of your home?
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Do you own rental income property?
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Do you have a second residence?
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Do you own investment property?
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Do you have a monitored security system?
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Do you regularly carry or keep at your residence more than $500 in cash?
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Do you own recreational vehicles: boat, jet-ski, camper, cycles, ATV's?
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Have you remodeled your home or have plans to do so in the near future?
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Do you have umbrella liability coverage?
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If you have umbrella coverage, are you also purchasing excess Uninsured and Underinsured Motorist Coverage?
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Do you have a swimming pool or trampoline in your yard?
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Do you have detached structures: gazebos, storage sheds, barns, garages, etc?
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Do you have pets?
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Do you have domestic help: a Nanny, Landscapers, House cleaners etc?
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Do you travel frequently outside the United States?
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Do you have a wood burning stove in your home?
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Do you have flood insurance?
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Are you aware that flood is excluded by all homeowners policy?
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Do you have Identity Theft Coverage on your Homeowners Policy?
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Do you have earthquake coverage on your homeowners policy?
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Do you believe your homeowners policy coverage will be enough to replace your home should you sustain a total loss?
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Would you be willing to assist us in preparing a residential replacement cost estimator on your home?
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Your Full Name: (required)
City: (required)
State: (required)
Zip Code: (required)
Daytime Phone: (required)
Email address: (required)
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