Name
*
First Name
Last Name
Email Address
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Are there any outstanding items that you would like us to address?
Have you refinanced or changed your mortgage company recently?
No
Yes
Do you own any single pieces of jewelry or watch that would cost more than $1,000 to replace?
No
Yes
Do you own vacant land that needs homeowners liability extension coverage?
No
Yes
Do you own a second home or seasonal property?
No
Yes
Do you have guns, or musical instruments, or fine arts in excess of $3,000 which you would like scheduled? Would you like this coverage explained and verified?
No
Yes
Do you store(own) Boats, ATV's, Motorcycles, Personal Water Craft, Snowmobiles, RV's, or Classic Cars at any of your properties?
No
Yes
Are you concerned about sewer backup coverage? Would you like this coverage explained and verified?
No
Yes
Are you concerned about Building Code Coverage. Do you want the coverage explained and verified?
No
Yes
Are you self employed and running either a part-time or full-time business from your home?
No
Yes
Your dwelling coverage limit is $_________. (Check your Declarations Or Call) Would you like this limit reviewed for sufficient coverage?
No
Yes
Have you acquired any rental or investment properties?
No
Yes
Are you concerned about obtaining earthquake coverage for your home?
No
Yes
Are you concerned about obtaining flood coverage for your home?
No
Yes
Would you like to have Identity Theft Coverage? (Identity Theft Coverage costs ONLY $30 annually for $25,000 coverage limits.)
No
Yes
What year was your roof installed?
Mid to High Net-worth individuals and families often ask about Personal Umbrella coverage to protect their assets. Would you like to learn about a Personal Umbrella Policy?
No
Yes
Have you or your spouse changed jobs in the last 5 years?
No
Yes
Do you an your spouse carry at least 10 times annual salary of life insurance outside work?
No
Yes
Considering the national debt, are you concerned about the impact on your retirement and saving if there is another 45% decline in the markets like in 2001 and 2008?
No
Yes
