| General |
N/A Yes No |
| Would you be interested in a personal catastrophe liability policy over your home and auto? The cost for $1 million is approximately $150.00 annually and up. |
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| Are you pleased with our service? |
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| Is there anything we can do that we are not? |
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| Do you own a business? |
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| If so, could we review the insurance? |
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Home |
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| If we do not currently insure your home, would you like us to review your current coverage? |
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| If not, would you like us to estimate the actual cost of the replacement? |
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| Do you own any jewelry, fine arts, silverware, furs, computers you would like to list on the policy? If so, please send us the details as your policy currently limits the coverage on these items. |
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| Would you like to add earthquake coverage? Approximate cost is .35 per thousand. |
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| Are you subject to floods? Would you like to purchase flood coverage? |
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| Do you own any other home or rental property we do not insure? If so, please describe locations in the comments box at the end of this form. |
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| Do you have burglar, fire alarms, or smoke detectors? If so, please state which in the comments box located at the end of this form. We want to make sure you are getting proper credits. |
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| Do you have a woodstove? Please state the last time it was inspected in the comment box at the end of this form. |
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| Do you conduct any business (including daycare) in your home? |
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| Would you like to add replacement cost on your contents if you do not have it already? |
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| Would you like to add home extended replacement protection? |
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Auto |
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| If we do not insure your auto presently, would you like us to review it? |
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| Would you like us to increase your liablility limits? |
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| Do we insure all vehicles in your household? If not, please provide the number and where they are insured in the comment box located at the end of this form. |
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| Do you want to add rental reimbursement for your auto if your vehicle is damaged in an accident? |
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| Do you want to add towing coverage for disablement of your vehicle? |
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| Do you have any special equipment that may need to have special coverage? Eg. customization, after market stereo, etc. |
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| Do you own any other motorized vehicles, such as a moped, motorcycle, minibikes, boats, golf carts, etc. |
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| Are all of the licensed drivers in the house listed on the policy? |
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Financial Services |
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| Would you like your life insurance reviewed? |
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| Would you like disability income, in the case of an accident or sickness? |
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| Would you like to review your need for long term care insurance? |
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| Do you have a mortgage term life insurance policy? |
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