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Please Complete the Following Information
Which Company are you currently Insured with?*
Thank you for choosing our agency to service your homeowner insurance needs. Your policy renewal is coming soon and we would like to take a few moments of your time to have you help us complete the following questionnaire.
These questions are intended as a guide for our agency to identify exposures and relevant changes to your insurance situation.
Policy Holder*
1. Do you have or have you added any valuable collections? i.e. Fine Arts, Coins, Jewelry, Guns, etc.*
If you answered yes to Question #1 please list collection type and estimated value in the area provided below.
Collection Type
Estimated Value
2. Do you keep children or operate a day care in your home?*
3. Is any part of your home used for business purposes?*
If you checked yes. Do customers ever come into your home?
4. Do you own a second residence? Vacation Property? Or a Rental Property?*
Please provide details in the space provided:
5. Do you own any boats, motorcycles, ATV's or any other motorized recreational vehicle?*
Please provide details in the space provided:
6. Have you made any renovations or additions to you property within the last 5 years?*
Please provide details in the space provided:
7. Would you like to add identity theft coverage to your policy? ($20 annual charge, please note the attached brochure in the letter you have received in the mail.*
8. Would you like to receive information on a Personal Liability Umbrella.*
***Typical cost for a $1,000,000 personal umbrella are less then $200/year. It works out to about $.50 per day.
9. Would you like a quote on any other lines of insurance?
***Please note when requesting to add coverage, we will contact you. Please do not assume a coverage has been added until it has been confirmed by our agency by phone or email.