Please complete this annual questionnaire and select the SUBMIT button at the bottom of the page.

Information provided will be kept confidential.

 

Contact Information

Name:
Street Address:
City:   State:    ZIP:
E-Mail Address:            Fax: () -
Home Phone: () -           Work Phone: () -
Policy #:

 

Annual Review Questionnaire
HOMEOWNERS

Have you done any remodeling, add-ons, outbuilding additions, etc.? Yes  No
Do you employ anyone in your home, such as a housekeeper, babysitter, or gardener? Yes  No
Do you own any boats, jet skis, or other watercraft? Yes  No
Do you own any snowmobiles, golf carts, or other recreational vehicles? Yes  No
Do you have any of the following items that you would like to schedule? Jewelry (exceeding $1,000 total value)
Silverware
Antiques or fine art
Collectibles, such as unique dishes, figurines, dolls
Guns (exceeding $2,000 total value)
Furs
Camera equipment
Personal computers
More than $200 in money, coins, or stamp collections
Are you interested in any of the following coverages?

Earthquake coverage
Flood insurance
Personal injury coverage
Refrigerated products coverage
Are you interested in water/sewer backup? $2,000
$5,000
$10,000
Do you presently have the following in your home? Deadbolt locks
Fire extinguishers
Smoke detectors
Do you have a security system for your home? Burglar
Fire
Ambulance
Do you own a second home or any other real property, such as a cabin, farm property or any income producing property? Yes No
Are you presently engaged in any form of farming or ranching? Yes No
Do you conduct any business or give private lessons in your home? (e.g. daycare, office, Avon, etc.) Yes No
Has your mortgage company changed? Yes No
Is this home unoccupied or being rented to others? Yes No
Do you have any of the following? Swimming pool
Diving board
Trampoline
Do you have any pets? Yes No
Would you like an estimate of your home's replacement cost at today's prices? Yes No
Would you be interested in an umbrella policy that extends your auto and home liability coverage to $1 million or more? Yes No
Do we write your auto insurance?
If not, can we give you a quote?
What month does your current policy expire? 		Yes No
Yes No
Do you have any of the following? Wood burning stove
Traditional fireplace
Freestanding fireplace
Additional comments:

 

Thanks for completing this questionnaire.