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Personal Information
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Checklist Questions
Do you have collectibles such as antiques, fine art, stamps, coins, or baseball cards?
Yes
No
Do you own valuable jewelry or furs?
Yes
No
Do you own costly sporting equipment or firearms?
Yes
No
Do you have valuable cameras or other photography equipment?
Yes
No
Do you have any alarms installed in your home?
Yes
No
Describe Alarms
Do you keep more than $100 cash in your home?
Yes
No
Are your personal belongings insured for their full replacement value?
Yes
No
Do you have children away at college?
Yes
No
Do you own tools, equipment, or instruments used in your trade or profession?
Yes
No
Do you operate an office or studio in your home?
Yes
No
Do clients come into your home to make purchases?
Yes
No
Do you baby-sit in your home?
Yes
No
Have you recently remodeled or redecorated your home?
Yes
No
Do you have plans to remodel or redecorate in the future?
Yes
No
If your home suffered an entire loss, would your insurance cover your home's full replacement value?
Yes
No
Are you interested in flood insurance for your home and personal property?
Yes
No
Are you interested in earthquake coverage?
Yes
No
Do you have a wood burning stove?
Yes
No
Do you have a swimming pool?
Yes
No
Do you own rental or investment property?
Yes
No
Do you own a vacation home?
Yes
No
If you rent, do you carry renter's insurance?
Yes
No
Do you plan to purchase a new vehicle this year?
Yes
No
List Potential Vehicles for New Purchase
Would you like us to provide you with an insurance estimate on the vehicle(s) you are considering?
Yes
No
Does our agency insure all of your vehicles?
Yes
No
Does your automobile policy specify by name all of the drivers in your household?
Yes
No
Do you routinely use vehicles you do not own?
Yes
No
Do you have non-factory installed equipment, such as car phones, stereos, or CD players in your automobiles?
Yes
No
Do you store CD's or cassette tapes in your car?
Yes
No
Do you own a vehicle with custom furnishings or equipment?
Yes
No
If your vehicle were in an accident, would your current automobile insurance reimburse you for a rental vehicle while yours is being repaired?
Yes
No
Do you own any of the following?
Camper
Moped
Golf Cart
RV/Motor Home
All-Terrain Vehicle
Boat or Personal Watercraft
Other
Other (Please Describe)
Do you carry at least a one-million-dollar umbrella liability policy?
Yes
No
Do you own a business?
Yes
No
Do we currently insure your business?
Yes
No
Do you plan to start a business?
Yes
No
Would you like a no-obligation review of your life insurance needs for your business?
Yes
No
Do you have sufficient liability or malpractice coverage?
Yes
No
Do you and your family have proper health insurance coverage?
Yes
No
Do you have disability income insurance?
Yes
No
Do other family members need such coverage?
Yes
No
Do you have life insurance which pays your mortgage in case of your death?
Yes
No
Are you insured for long-term supervised health care?
Yes
No
Do you know anyone else who could benefit from a no obligation insurance review from our agency?
Yes
No
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