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.

* All fields required.

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

Checklist Questions
1) Do you have collectibles such as antiques, fine art, stamps, or coins?	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
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
12) Do you baby-sit in your home?	Yes No
12) Do you maintain any samples or articles of sale on your premises?	Yes No
13a) Have you recently remodeled or made an addition to your home?	Yes No
7) Are your personal belongings insured for their full replacement value?	Yes No
5) Do you own rental or investment property?	Yes No
5) Do you have any alarms installed in your home?	Yes No
17) Do you have a wood burning stove?	Yes No
18) Do you have a swimming pool?	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
21) If you rent, do you carry full insurance protection on household possessions?	Yes No
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 or GPS devices in your automobiles?	Yes No
27) Do you own a vehicle with custom furnishings or equipment?	Yes No
28) 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
29) Do you own any of the following? Boat or Personal Watercraft Camper Motorcycle RV/Motor Home Golf Cart Moped Other:
14) Would you be covered for a million dollar judgment?	Yes No
32) Are you interested in umbrella coverage?	Yes No
32) Do you have or plan to start a business?	Yes No
8) Does your family have adequate life insurance coverage?	Yes No
36) Do you have disability income insurance?	Yes No
34) Do you have sufficient liability or malpractice coverage?	Yes No
40) Do you know anyone else who could benefit from a no obligation insurance review from our agency? Name: Phone Number: Email 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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