It is time for an insurance check up!  To better serve you and eliminate possible gaps in your insurance coverage, please complete this questionnaire.  We will use the information to evaluate the adequacy of your present coverage and will advise you of any changes that may be needed.  This information, like all of your personal data, will be kept in strict confidence.

Please answer the following questions below and click on SUBMIT.  We will receive an email with your answers and contact you in person if there are any questions or follow-up actions required.

First Name                 Last Name

Street Address      Street Address cont'd  

City      State      Zip Code 

Policy Number        Email Address  

1.  Do you serve on any charitable, social, or governmental boards?   Yes   No

2.  Do you feel comfortable with the amount of insurance you have on your home and personal belongings?   Yes   No

3.  Do you own a business?  Yes   No   If Yes, do clients visit your home as part of your business activities?   Yes   No

4.  Do you feel comfortable with the current coverage on your jewelry, fur, antiques, fine art or collectibles?  Yes   No Unsure

     If no or unsure, please include the most recent appraisal for the item(s).      Total amount

5.  Do you own a boat, Jet Ski, golf cart, ATV, Go-Kart, trailer or any other costly sporting equipment not listed in your policy? Yes   No

     If not, do you ever rent one from a dock, etc.? Yes   No

6.  Would you be interested in an earthquake, flood, water back-up or identity theft coverage quotation?  Yes   No

7.  Do you have any residential employee such as a housekeeper, home health care provider, or nanny?  Yes   No

8.  Do you ever have an occasion to rent a vehicle?  Yes   No

9.  If you do not already have it, would you be interested in obtaining an umbrella quote?  (An umbrella policy provides an additional layer

    of liability coverage over and above your basic policy) Yes   No

10.  Are you confident that all of your life, health, and disability insurance needs are being met?  Yes   No Unsure

On a scale of 1 to 5 with 1 being Very Dissatisfied and 5 being Very Satisfied how would you rate our Service?

Would you be willing to refer your friends and family to our agency and if so please complete the name and phone numbers in the remarks section.  Thank you. Yes   No

Remarks: