| Your
personal checklist Just
as your health needs an annual checkup, so does your insurance
program. Although you may be unaware of it, your financial
profile has probably changed over the past year. Therefore,
you may need to adjust your insurance coverage. Please take
the time to complete this checklist and mail it back to us
in the enclosed envelope. Or, if you prefer to discuss your
insurance needs in person, please call to schedule an appointment.
Name_____________________________________________
Address___________________________________________
City_________________ State_____________ Zip_________
Phone_________________ Email_______________________
Check yes or no. If yes, on a separate piece of paper, please
provide a brief description or explanation.
Yes No
1. Do you have collectibles such as antiques, fine art, stamps,
coins, or baseball cards?
Yes No
2. Do you own valuable jewelry or furs?
Yes No
3. Do you own costly sporting equipment or firearms?
Yes No
4. Do you have expensive cameras or other photography equipment?
Yes No
5. Do you have any alarms installed in your home? If so, what
types and are they monitored?
Yes No
6. Do you keep more than $200 cash in your home?
Yes No
7. Are your personal belongings insured for their full replacement
value?
Yes No
8. Do you have children away at college?
Yes No
8a. If so, are their possessions insured?
Yes No
9. Do you own tools, equipment, or instruments used in your
trade or profession?
Yes No
10. Do you operate an office or studio in your home?
Yes No
11. Do clients come into your home to make purchases/conduct
business?
Yes No
12. If you have a basement, are you concerned with water backup
through sewers or drains?
Yes No
13. Do you or your resident children babysit for a fee?
Yes No
14. Do you have a dog, cat, or other animal?
Yes No
15. Have you recently remodeled or redecorated your home?
Yes No
15a. Do you have plans to do so?
Yes No
16. If your home suffered a total loss, would your insurance
cover your home's full replacement value?
Yes No
17. Are you interested in flood insurance for your home and
personal property?
Yes No
18. Are you interested in earthquake coverage?
Yes No
19. Do you use a wood, coal, or pellet-burning stove?
Yes No
20. Do you have a swimming pool?
Yes No
21. Do you own rental or investment property?
Yes No
22. Do you own a vacation residence (e.g., condo, cabin, or
trailer)?
Yes No
23. If you rent, do you carry renters insurance?
Yes No
24. If you own a condo, do you have condo insurance?
Yes No
25. Do you plan to purchase a new vehicle this year?
Yes No
25a. If so, would you like us to provide you with an insurance
estimate on the vehicle(s) you are considering? Write year,
make, model, and type of vehicle(s):
Yes No
26. Does our agency insure all your vehicles?
Yes No
27. Does your automobile policy list the names of all drivers
living in your household?
Yes No
28. Do you routinely drive vehicles you do not own?
Yes No
29. Do you have CD players, cassette decks, or other non-factory
installed equipment (like car phones, stereos, etc.) in your
car?
Yes No
29a. If so, would you like a quote on insuring those items?
Yes No
30. Do you own a vehicle with custom furnishings or equipment
(e.g., a conversion van)?
Yes No
31. If your vehicle were damaged in an accident, would you
need your current automobile policy to reimburse you for a
rental car while yours is being repaired?
Yes No
32. Do you own any of the following recreational vehicles?
Boat
Camper All-Terrain
Vehicle Motor Home
Golf Cart
Snowmobile
Motorcycle Moped
Others____________
Yes No
33. Do you carry at least a $1,000,000 umbrella liability
policy?
Yes No
34. Do you own a business?
Yes No
34a. If so, do we currently insure it?
Yes No
35. Do you plan to start a business?
Yes No
36. Would you like a no-obligation review of your life insurance
needs for your business (e.g., key person life insurance)?
Yes No
37. Do you have adequate professional liability or malpractice
coverage?
Yes No
38. Do you and your family have proper health insurance coverage?
Yes No
39. Do you have disability income insurance?
Yes No
39a. Do other family members need such coverage?
Yes No
40. Do you have life insurance that would pay your mortgage
in the event of your death?
Yes No
41. Would you like a no-obligation review of your personal
life insurance needs?
Yes No
42. Do you have long-term care coverage to protect your savings
from expensive nursing home costs?
Yes No
43. Do you know anyone else who might benefit from a no-obligation
insurance review from our agency?
Yes No
44. To serve you better, do we have your correct mailing address?
Updated Personal Information: ____________________________________
____________________________________________________________
____________________________________________________________
Please sign and date this form and return it to us in the
enclosed envelope.
Signature___________________________________ Date__________
Please call or stop by if you have any questions or concerns.
We are happy to serve your needs, and appreciate your time
and valuable input. Thank you!
|