Review Form

As your life changes, your insurance needs to change with it. Reviewing and updating your insurance program is an important part of protecting your assets. We’ve developed a review questionnaire to trigger changes that have occurred. The purpose of the form is to make sure your insurance program is up to date with your life. The questions are designed to address the areas that change most frequently.
Name
Address
Address2
City
State
Zip
Phone
Email
List all names of drivers in your household.
List all vehicles in the household.
Do any drivers drive a company car?
 Yes
 No
Do any drivers qualify for a good student discount?
 Yes
 No
Are any drivers living away at school without a vehicle? (>100 miles away)
 Yes
 No
Lease/Loan Gap. For new vehicles only. This coverage makes up for the heavy depreciation applied to new vehicles. Your loan or lease obligation could be more than the car is worth if it is badly damaged in an accident. This coverage fills the gap between the current value of the car and its lease/loan cost. WOULD YOU LIKE TO BE CONTACTED REGARDING THIS OPTION?
 Yes
 No
Uninsured Motorists Property Damage. If you only carry liability coverage, for roughly $15 a year, you can have coverage to protect your older vehicle against an accident involving an uninsured driver. This coverage pays when your vehicle is damaged by an uninsured driver. WOULD YOU LIKE TO BE CONTACTED REGARDING THIS OPTION?
 Yes
 No
Electronic Equipment coverage. If your vehicle is equipped with after-market electronic equipment, it isn’t automatically covered by your auto policy unless you add this option. Items include after-market CD players, permanently installed car phones, etc. WOULD YOU LIKE TO BE CONTACTED REGARDING THIS OPTION?
 Yes
 No
Water Back-Up - This coverage pays for the damage caused by a back-up of sewer or drains in your basement. Our companies vary in their limit of coverage, so check with us. WOULD YOU LIKE TO BE CONTACTED REGARDING THIS OPTION?
 Yes
 No
Do you own...
 Antiques
 Cameras
 Collections
 Fine Arts
 Firearms
 Furs
 Musical Instruments
 Jewelry in excess of 1000
 Are any of the above items used professionally?
Do you have...
 Basement
 Finished Basement
 Boat
 Camper
 Golf cart
 Home-based business
 Motorcycle/moped. Etc…
 Office in the home
 Recreational vehicle
 Rental property
 Seasonal property
 Snowmobile
 Student away from home
Extended Coverage, Contents - This coverage will extend the items insured against from a list of twelve to a clause that reads: If it’s not excluded, it’s covered. This dramatically increases the likelihood of a claim being covered. WOULD YOU LIKE TO BE CONTACTED REGARDING THIS OPTION?
 Yes
 No
Umbrella Coverage - An umbrella extends your home or auto liability insurance to an additional $1 million. It costs between $150 and $250 a year. Quite a bargain for $1 million! WOULD YOU LIKE TO BE CONTACTED REGARDING THIS OPTION?
 Yes
 No