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Annual Review Questionnaire


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
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Last Name
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Street
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City
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State / Province
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ZIP / Postal Code
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Primary Phone Number
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E-Mail Address
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Policy #
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Review Questionnaire
Do we insure all vehicles in your household?
Required

Are vehicles titled in other names?
Required

If yes, please list
Optional
How are your vehicles used?
Optional


Hold down the Ctrl Key to make multiple selections.
Please list lien holders for all vehicles.
Required
Are any vehicles garaged elsewhere?
Required

If yes, please list where
Optional
Do you have any equipment in your vehicles that was not factory installed?
Required

Please give values (we will need sales receipts)
Stereo
Optional
Speakers
Optional
Amplifiers
Optional
DVD players
Optional
Topper
Optional
Camper
Optional
Bed liner
Optional
Toolbox(es)
Optional
Customized equipment
Optional
Wheels
Optional
Other (please explain and give value)
Optional
Do you have any vehicles furnished for your regular use that you do not own, such as a company vehicle?
Required

Do you want Rental Reimbursement coverage in the event that your vehicle is damaged in an accident? (Available for full coverage vehicles)
Required

Do you want Towing or Roadside assistance coverage?
Required

Do you need loan/lease (GAP) coverage?
Required

Do any of these discounts apply for you?
Optional


Hold down the Ctrl Key to make multiple selections.
Do you own any boats, motorbikes, motor homes, or other recreational vehicles such as snowmobiles, ATV's, or golf carts?
Required

If yes, please list
Optional
If we do not now provide your Homeowner's insurance or renters insurance, may we give you an estimate? Please list the month your current policy expires.' Life-Health, Umbrella?
Required

Please list
Optional
If we do not now provide your Life insurance or Health insurance, may we give you an estimate?
Required

Please list the month your current policy expires.
Optional
If we do not now provide your Umbrella insurance, may we give you an estimate?
Required

Please list the month your current policy expires.
Optional
Additional comments
Optional
Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.



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Al Shank Insurance, Inc is a professional, independent agency with the customer in mind. We have relationships with dozens of insurance companies, allowing you to get the right price with the right service.

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Liberal, KS 67905

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