Use this text file to select items you would like to use in your own coverage review forms. Copy & paste each item you select from this file into your own coverage review form document, then add your own items. Personal Insurance Review: We will use this review to evaluate your present coverage and if any changes are in order, we will contact you. This information, like all of your personal business, will be kept in the strictest of confidence. Full Name Address City Email Home Phone Work Phone (Required) Years at current residence Occupation Please note: Insurance coverage cannot be bound without a written binder from our office. Policies presently owned… Personal automobile policy: My present policy expires __________ Month _________Year Currently insured by _______________________________________________________ Homeowners policy: My present policy expires ___________ Month ____________Year Currently insured by _______________________________________________________. Personal umbrella policy: My present policy expires ___________ Month ____________Year Other policy _______________________ My present policy expires ___________ Month ____________Year Protection preferences: Excessively low: Absolute minimum policy limits / coverage forms required by law or contract. About average: Limits / coverage forms that offer average protection under typical circumstances. Above average: Limits / coverage forms that are significantly better than average, when available. Deductible preferences: $250 or less: I like my insurance to cover the little things even though the premiums are higher. $500 to $1,000: Keep my premiums affordable, but maintain my coverage for serious dollar claims. Over $1,000: I am not concerned about minor claims. I’ll pay for events below my deductible. Contact preferences: In the future, you may contact me by the following method(s). Check all that apply: __Telephone call __Email __Postal mail __Newsletter Other__________ Enter brief details on any personal insurance claims in the past X years: Auto insurance: ________________________________________________________________________ Home insurance: ________________________________________________________________________ Other policy: ________________________________________________________________________ Reason(s) why you are seeking another policy… Check all that apply. __Better total annual premium __Better payment plan __Better quality of service __Better insurance company __Better coverage Other_________________________ Would you consider adding excess liability insurance or increasing existing coverage? Are you subject to floods? Would you like to purchase flood coverage? Regarding auto insurance, have you: Added or removed a driver that we don’t know about? Acquired or sold a vehicle we don’t know about? Decided you want to increase your liability coverage? Decided you want a higher deductible to reduce premium amounts? Changed how you drive your vehicle to work? Had a driving student with a ‘B’ or higher average that now qualifies for a Good Student Discount? 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. Would you like to add earthquake coverage? Approximate cost is .35 per thousand. Are you satisfied with the service you are receiving? Are you pleased with our service? Do you have a mortgage term life insurance policy? Do you have any questions or comments about your insurance protection? Is there anything we can do that we are not? Would you like disability income, in the case of an accident or sickness? Would you like to review your need for long term care insurance? Would you like your life insurance reviewed? Would you like information on medical insurance? Are you interested in Identity Theft Protection? 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. Do you conduct any business (including daycare) in your home? Do you need insurance on your business? Do you need to review or purchase life insurance coverage? Do you own a boat or jet ski? Do you own a business? Do you own any business equipment? Do you own any cars, trucks, motorcycles or motorhomes that we do not insure for you? 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. Do you own any other motorized vehicles, such as a moped, motorcycle, mini-bikes, boats, golf carts, etc. Do you own or rent any other homes by yourself or with others that we do not insure? If we do not insure your home, when does your home insurance renew? If we do not currently insure your home, would you like us to review your current coverage? If we do not insure your auto presently, would you like us to review it? Would you like information on a Trust? Would you like information on disability protection? Send me more information on… Home Life Valuable Items Financial Planning Auto Health Excess Liability Business Other Do you have any employees? Do you need coverage for backup of sewers, flood or earthquake? Is any student at school over 100 miles from primary residence? Are you interested in increasing your liability coverage or uninsured/underinsured ? Are you interested in purchasing a $1,000,000 Umbrella Liability Policy? Do any of your vehicles have custom equipment? Do you drive a company car or other vehicle on a regular basis: Do you drive a vehicle is used in business? Do you have a loan on a vehicle on your policy? Do you have any outbuildings or separate garages on your property? Do you serve on charitable, social or government boards? Have you done any remodeling or made other improvements to your home? Is the amount of insurance on your home less than it would take to rebuild it? Would you be interested in a broader coverage on your contents? Do you have collectibles such as antiques, fine arts, stamps or coins? Do you own jewelry, furs or silverware valued at over $1000? Do you have any special equipment that may need to have special coverage? Do you own any costly sporting goods, guns or musical instruments? 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. Do you want to add rental reimbursement for your auto if your vehicle is damaged in an accident? Do you want to add towing coverage for disablement of your vehicle? If you do not have this protection now, would you like to add full glass, towing, or rental? Is any vehicle driven less than 12,500 miles a year? Is the garaging address for any auto is different from your residential address? Within the past year, have you: Made new improvements or upgrades? (addition/remodel) Had a student living away at school that we didn’t know about? Installed a burglar/fire alarm or dead bolt locks? (possible credit) Decided you need new or additional Water Back-Up coverage? Decided you need new or additional Flood or Earthquake coverage? Purchased, inherited, or been gifted items that need to be covered? Checked the VALUE lately for your currently insured items? (We can only pay up to the amount that is insured.) Put valuable items in a bank vault that used to be at home? Would you like to add home extended replacement protection? Would you like to add replacement cost on your contents if you do not have it already? Would you like us to increase your liability limits? Are all of the licensed drivers in the house listed on the policy? Do you have a woodstove? Please state the last time it was inspected in the comment box at the end of this form. 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. Do you own a pool? If you do own a pool, does it have any features or water slides? Do you have home, condo or renter insurance with another company? Does your spouse have a separate auto policy? Please indicate protection options you are interested in. Not all options are available with all insurance carriers that we represent. Accident forgiveness Auto loan/lease gap coverage Disappearing deductible Vehicle must have full coverage New vehicle replacement value Pet injury related to accident- up to $500 Comments: Please provide any additional comments that will help us make sure you have the appropriate protection: Additional Comments or Questions: If you've had changes in your life or are not sure if we have all the information we need, please complete the information below: ADDITIONAL COMMENTS: