Your Name (required)

Your Email (required)

Phone

Has anything changed in your personal situation that you have not already informed us of such as:

1. House addition/renovation/outside structure/finished basement
Yes No 

2. Addition of Alarm System
Yes No 

3. Student away a college AND/OR Good Student Credit on Auto
Yes No 

4. Do you drive a company furnished vehicle
Yes No 

5. Purchase of RV/Motor Home/Watercraft/jet ski/snowmobile/golf cart
Yes No 

6. Would you like a quote to:

Increase your current liability limit?
Yes No 

Increase Uninsured/Underinsured Motorist limit?
Yes No 

Increase or add Medical Payments?
Yes No 

For comprehensive & collision if not presently provided?
Yes No 

Add Extended Transportation Expense Coverage or Towing Coverage?
Yes No 

7. Are all licensed drivers in your household listed on your policy?
Yes No 

8. Your homeowner policy provides limited coverage for Jewelry, Furs, Fine Arts, Silverware, Guns, and Money. Would you like to specifically insure any items in these categories?
Yes No 

9. Do you need to change the value of any item presently scheduled or make any additions or deletions? If not, please review the items currently listed on the schedule for accuracy. Jewelry appraisals should be updated by the insured every 3-5 years to keep the values accurate.

Yes No 

10. Do you use your residence for any business, office or baby-sitting?

Yes No 

11. Do you own any rental or seasonal homes not insured through us?

Yes No 

12. If a condominium or renter:

A. Is the Additions and Alterations limit adequate? (Dwelling Limit)

B. Do you need additional Loss Assessment Coverage?

Yes No 

13. Have there been any changes in occupancy in the past year?

Yes No 

14. Coverage for Fair Rental Value/Additional Living Expense is provided on a limited basis. Would you Be interested in a quote to increase this coverage? NOTE: IF COVERAGE IS WRITTEN ON A BASIC FIRE FORM, COVERAGE IS NOT AUTOMATIC AND MUST BE ADDED BY ENDORSEMENT.
Yes No 

15. Are you interested in a quote for Excess Liability (umbrella policy) coverage?

Yes No 

16. If you already have an Excess Liability policy, are you interested in quote for higher limits of liability? NOTE: IF YOU CURRENTLY HAVE EXCESS LIABILITY COVERAGE, BE AWARE THAT YOU MUST MAINTAIN A MINIMUM PRIMARY LIMIT FOR ALL VEHICLES IN YOUR HOUSEHOLD.

Yes No 

17. Would you be interested in a quote for individual benefits coverage(s):

Yes No 

18. Would you like to give us a referral, someone that can benefit from our services?:

Name:

Number: