Knight Crockett Miller Insurance Group


	The purpose of this 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. Please phone us if any of the review generates questions on your part.

CONTACT INFORMATION

Name

Phone - Home

Street Address

Phone - Work

City

Phone - Other

State

Zip code

Email Address

HOMEOWNERS REVIEW

Do you own . . .

Antiques

YES NO

Firearms

YES NO

Cameras

YES NO

Furs

YES NO

Collections
(stamps, coins, ...)

YES NO

Jewelry
(in excess of $1,000)

YES NO

Fine Arts

YES NO

Musical Instruments

YES NO

Are any items used professionally?

YES NO

If you own any of the above items please indicate their value below.

Do you have a . . .

Basement

YES NO

Office in your home

YES NO

if so, is it finished?

YES NO

Recreational vehicle

YES NO

Boat

YES NO

Rental property

YES NO

Camper

YES NO

Seasonal property

YES NO

Golf cart

YES NO

Snowmobile

YES NO

Home-based business (Mary Kay, Pampered Chef,...)

YES NO

Student away from home

YES NO

If yes, please provide details:

OPTIONS TO CONSIDER

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.

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 bargin for $1 million!

QUICK TIP:
Ask yourself the last time you had a claim. If it was more than five years ago, you're wasting money by having a deductible less than $500.

Would you like to be contacted regarding this option? YES NO

AUTOMOBILE REVIEW

List names of all drivers in your household.

List all vehicles in your household.

Do any drivers drive a company car?

YES NO

Has any vehicle been customized?

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

OPTIONS TO CONSIDER

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 files the gap between the current value of the car and its lease/loan cost.

Uninsured Motorists Property Damage:
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...

Customization:
If your vehicle has been customized with spoilers, televisions, special paint jobs, etc..., make sure you let us know. Without identifying a value for these specialties, there is no coverage for them at claim time.

Would you like to be contacted regarding this option? YES NO

QUICK TIP:
The single most important part of your auto policy is liability coverage. Your limit should be at least $300,000 (or $100,000/300,000.)

Would you like to be contacted to further discuss your insurance program? YES NO

Thank you for your continued business.
We look forward to servicing your account for years to come.