Personal Insurance Checklist

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Just as your health needs an annual checkup - so does your personal insurance program. Although you may not be aware of it, your financial profile changed over the past year. To make sure you, your family and your property are adequately insured for those changes, please complete the questionnaire and press the "Send Checklist" button at the end of the form. We will use the information in your response to evaluate the adequacy of your current insurance program.

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Personal Information
Full Name:
Address:
City:
State:	Zip:
Daytime Phone:	Night Phone:
Best Time To Call:	AM PM
E-mail Address:

Checklist Questions
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 valuable cameras or other photography equipment?	Yes No
5) Do you have any alarms installed in your home?	Yes No
Type of alarm:
6) Do you keep more than $100 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
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?	Yes No
12) Do you baby-sit in your home?	Yes No
13a) Have you recently remodeled or redecorated your home?	Yes No
13b) Do you have plans to remodel or redecorate in the future?	Yes No
14) If your home suffered an entire loss, would your insurance cover your home's full replacement value?	Yes No
15) Are you interested in flood insurance for your home and personal property?	Yes No
16) Are you interested in earthquake coverage?	Yes No
17) Do you have a wood burning stove?	Yes No
18) Do you have a swimming pool?	Yes No
19) Do you own rental or investment property?	Yes No
20) Do you own a vacation home?	Yes No
21) If you rent, do you carry renter's insurance?	Yes No
22) Do you plan to purchase a new vehicle this year?	Yes No
Would you like us to provide you with an insurance estimate on the vehicle(s) you are considering? If so, list the type of vehicle(s):
23) Does our agency insure all of your vehicles?	Yes No
24) Does your automobile policy specify by name all of the drivers in your household?	Yes No
25) Do you routinely use vehicles you do not own?	Yes No
26) Do you have non-factory installed equipment, such as car phones, stereos, or CD players in your automobiles?	Yes No
27) Do you store CD's or cassette tapes in your car?	Yes No
28) Do you own a vehicle with custom furnishings or equipment?	Yes No
29) If your vehicle were in an accident, would your current automobile insurance reimburse you for a rental vehicle while yours is being repaired?	Yes No
30) Do you own any of the following? Boat or Personal Watercraft Camper All-Terrain Vehicle RV/Motor Home Golf Cart Moped Other:
31) Do you carry at least a one-million-dollar umbrella liability policy?	Yes No
32a) Do you own a business?	Yes No
32b) Do we currently insure it?	Yes No
33) Do you plan to start a business?	Yes No
34) Would you like a no-obligation review of your life insurance needs for your business?	Yes No
35) Do you have sufficient liability or malpractice coverage?	Yes No
36) Do you and your family have proper health insurance coverage?	Yes No
37) Do you have disability income insurance?	Yes No
38) Do other family members need such coverage?	Yes No
39) Do you have life insurance which pays your mortgage in case of your death?	Yes No
40) Are you insured for long-term supervised health care?	Yes No
41) Do you know anyone else who could benefit from a no obligation insurance review from our agency? Name: Phone Number:
42) What is your correct mailing address?

Additional Comments or Questions

Please click the "Send Checklist" button to send your Personal Insurance Checklist.

Phone: 678.297.7977 Toll Free: 1.800.378.0766 Fax: 678.297.9575

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