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Coverage Review

Excellent service and has client's best interests in mind at all times. They instill confidence in the advice given.

Bernie & Star Sitron, Creamery

Personal Lines Coverage Review

Circumstances change and we want to make sure that your current auto, homeowner's and other personal lines coverages are up-to-date. We also want to assess any gaps that may exist in your current coverage and provide you with information about options to fill these gaps. Please complete the series of questions below, providing details where requested. We will contact you once we receive this information and give you an assessment of your current coverage and any options or special needs.

Contact Information

* Name:
* Email:
Address:
City:
State:
Zip:
* Phone:
	* Required Fields

Automobile

Would you like quotes on higher deductibles to lower your premiums?	Yes No
Are there additional household members who are licensed drivers that are not listed on your policy?	Yes No
Are there any vehicles on your policy that are not titled to you and/or your spouse?	Yes No
Have you retired or changed the commute distance for any of your vehicles? If so, please provide details.	Yes No

Are any of your personal autos regularly used for business purposes, including incidental use such as delivery or snow plowing?	Yes No
Are you or any of your family members furnished an auto for your regular use such as a company vehicle furnished by an employer?	Yes No
Do you often rent vehicles for personal or business use? If so, provide details.	Yes No

Do you own any trailers not included on your auto insurance policy?	Yes No
Do you own a pick-up truck or van which has been customized? If so, describe customization and value.	Yes No

Do any of your vehicles contain equipment such as stereos, telephones, televisions, VCRs, DVD players or other equipment that were not factory installed? If so, provide details.	Yes No

Are any drivers in your household students away at school with or without a vehicle? If so, provide school location and details.	Yes No

Do you have any students who may qualify for driver training and/or good student discounts? If so, provide details.	Yes No

Have any drivers age 55+ completed a defensive driver course within 3 years?	Yes No
Does your auto policy list loss payees or lessors whose interest has been satisfied? Tell us about any such interests that should be deleted.	Yes No

Homeowner's or Renter's

Are any members of your household not related to you? If so, provide details.	Yes No

Do you have children who are full time college students?	Yes No
Are any of your family members living in a nursing home or assisted living facility?	Yes No
Do you own any other real estate such as a secondary home or farm land that is not scheduled or covered on your homeowner's policy? If so, provide details.	Yes No

Do you own any property rented to others not listed or covered by your homeowner's policy? If so, provide details.	Yes No

Do you own any structures that are not residences that are located away from your home?	Yes No
Do you live in a condominium, a home that is part of a homeowner's association or a neighborhood development in which you are assessed for the maintenance of the property?	Yes No
Do you regularly conduct any business activities from your residence?	Yes No
Do you use any portion of your residence or any detached structure at your home for any business purposes? If so, please give details.	Yes No

Do you or any member of your family baby-sit or operate any type of child daycare business?	Yes No
Have you installed any burglar or fire alarm systems? If yes, please provide details.	Yes No

Since your homeowner's policy was written, have you remodeled or made improvements to your home? If so, provide details.	Yes No

Do you have a finished basement?	Yes No
Do you have a sump pump?	Yes No
Do you have any business or professional tools or equipment stored at your home?	Yes No
Do you have a trampoline?	Yes No
Do you have a wood burning stove?	Yes No
Do you have a swimming pool? If so, is it above or in ground? Do you have a diving or sliding board? Is it fenced in Yes or No?	Yes No
Do you have an underground storage tank?	Yes No
Do you have a dog, horse or other unusual pets/animals? If yes, please provide specifics, including breed.	Yes No

Are there any uneven sidewalks, tripping hazards or stairs (4 or more steps) without a railing at your home?	Yes No
Your homeowner's policy contains limitations in coverage for certain types of property. Do you own items not specifically covered now in any of these categories: Jewelry Furs Silverware, gold ware or pewter Firearms Cameras or video equipment Computers Stamps, coins or other collections Antiques, paintings or other fine arts Musical instruments

Miscellaneous

Do you own a recreational vehicle? (ex. camper, all terrain vehicle, snowmobile, golf cart, motorcycle, segway, scooter or dirt bike)	Yes No
Do you own any watercraft including jet skis?	Yes No
Do you travel outside the United States for pleasure or business? If so, provide details.	Yes No

Would you like information about any of these insurance coverages?	Flood Insurance Mine Subsidence Earthquake