Annual Coverage Review

Automobile

• Have you considered increasing your deductibles to lower your premium?
  Yes No
• Are all of the licensed drivers in your household listed on your automobile policy? (Your insurance company cam deny a claim if all household members and people who use your car on a regular basis are not listed and have a claim.)
  Yes No
• Have you installed a car stereo, CD player, or speakers in your car?
  Yes No
• If you own a pickup or van, does it have any customized equipment, such as a snowplow or camper?
  Yes No
• Are any of your vehicles used for business?
  Yes No
• Do you want Rental Car ("substitute transportation") coverage in case your car is damaged in an accident?
  Yes No
• Do you own classic or antique cars?
  Yes No
• Do you have a teenager who will be getting their license within 6 months?
  Yes No

Homeowners/Renters

• Have you considered increasing your deductible to lower your premium?
  Yes No
• Do you presently have a burglar, fire or smoke alarm in your home?
  Yes No
  If yes, what kind(s)?
• Do you own any boats, motorbikes, ATVs, golf carts, snowmobiles or RVs?
  Yes No
• Do you own any antiques, fine arts, jewelry, high end camera or video equipment, collections (such as figurines, dolls, baseball cards) glassware, goldware, silverware or pewterware valued in excess of $2500?
  Yes No
  

  (Your policy may limit coverage for these items in the event of a loss, depending upon the extent of the collection or item(s) and their condition/limits. All of these items can be insured separately on a schedule - which will eliminate or reduce your deductible and significantly broaden coverage. Regardless of how you choose to insure them, we recommend that you send us a list of the items for retention in your file to make settling any future losses easier. )

• Do you have a coin or stamp collection?
  Yes No
• Do you own any guns?
  Yes No
• Would you be interested in adding Earthquake or Flood insurance to your policy?
  Yes No
  

  (Earthquake losses are not covered unless your policy has an Earthquake endorsement. Flood damage is excluded on your homeowner's. However, you can purchase a Flood policy.)

• Have you significantly increased the replacement value of your home recently through an addition to the main structure or the construction of a garage or finished basement?
  Yes No
• Do you keep business personal property (including computer equipment) valued in excess of $2500 in your home?
  Yes No
  

  (Your policy limits coverage for personal business property at your residence premises to $2500. You may increase this limit for an additional premium. It limits away-from-residence coverage to just $250.)

• Do you have valuable computer hardware or software that may require additional insurance protection?
  Yes No
• Do you conduct any business, give private lessons, or have an office in your home?
  Yes No
  

  (Your policy excludes all business exposures - except for limited business personal property coverage - unless it is specifically insured by endorsement. The homeowner's policy can add one or more endorsements for property and/or liability coverage for your business, depending on the type of business and where your business office/site is located.)

• Do you perform day care or babysitting services in your home?
  Yes No
  If "yes", please answer the following:
  - How many children at one time?
  - How often?
  - Do you charge a fee? If so, what is the fee?
  
• Would you be interested in protecting your personal assets by purchasing an Excess Liability (Umbrella) policy which extends your Automobile and Homeowner's liability coverage to $1,000,000 or more?
  Yes No
• Do you rent any part of your home to others?
  Yes No
  If yes, please describe:
• Do you own other property or land?
  Yes No
  Address
• If you own rental property, is it currently rented out?
  Yes No
• Do you have a vacation or second home?
  Yes No
  Address
• Do you have domestic employees?
  Yes No
  If yes, provide details of work, hours and pay.
  
• Do you have a trampoline, underground fuel tank or knob & tube wiring?
  Yes No
• Do you have an above ground or in-ground swimming pool?
  Yes No
  If yes, is it fenced and gated?
  Yes No
  
• Do you have any structures on the premises such as a barn, detached garage, pool house or shed?
  Yes No
  

  (A basic homeowoners policy provides coverage of 10% of the dwelling coverage limit for all other structures.)

• Is there a commercial structure on your premises?
  Yes No
  If yes, please describe
  
• Do you have a wood, pellet or coal stove?
  Yes No
  If yes, was it professionally installed?
  Yes No
  If yes, have the chimney and flue been cleaned and inspected within the last 12 months?
  Yes No
• Do you own a dog or dogs?
  Yes No
  If yes, what breed(s)?

Personal Financial Security

• Do you feel you have an adequate level of life insurance to maintain your family's lifestyle, provide for education, etc.?
  Yes No
• Does your spouse or partner also have life insurance?
  Yes No
• Do you feel that you have adequate disability income insurance in case anyone in the household is injured or becomes ill and is unable to work?
  Yes No
• Are you concerned about estate taxes?
  Yes No
• Do you have an older relative who may require long term care?
  Yes No
• Do you have a retirement program through work, such as a 401(k)?
  Yes No
  If yes, are you concerned that it may not be adequate to maintain your lifestyle post-retirement?
  Yes No
  
• Are you interested in information about tax-favored savings programs?
  Yes No
  - IRAs, Roth IRAs
  - College Savings
  - Long Term Care
  
• Other areas of interest:
  

Questions or Concerns

Please use this space to jot down any specific questions you would like us to address with you.

* Required information. Please note that insurance coverage cannot be bound without a written binder from our office.