Annual Review Questionnaire

Let us help you
620.624.2559

Personal Information
First Name Required
Last Name Required
Street Required
City Required
State / Province Required
ZIP / Postal Code Required
Primary Phone Number Required
E-Mail Address Required
Policy # Required
Review Questionnaire
Have you done any remodeling, add-ons, outbuilding additions, etc.? Required	Yes No
Is yes, please list Optional
Do you employ anyone in your home, such as a housekeeper, babysitter, or gardener? Required	Yes No
Do you own any boats, jet skis, or other watercraft? Required	Yes No
Do you own any snowmobiles, golf carts, or other recreational vehicles? Required	Yes No
Do you have any of the following items that you would like to schedule? Optional	Jewelry (exceeding $1,000 total value)Silverware Antiques or fine artCollectibles, such as unique dishes, figurines, do Guns (exceeding $2,000 total value)Furs Camera equipmentPersonal computers More than $200 in money, coins, or stamp collectio
Are you interested in any of the following coverages? Optional	Earthquake coverage Flood insurance Personal injury coverage Refrigerated products coverage
Are you interested in water/sewer backup? Optional	$2,000 $5,000 $10,000
Do you presently have the following in your home? Optional	Deadbolt locks Fire extinguishers Smoke detectors
Do you have a security system for your home? Optional	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? Required	Yes No
Are you presently engaged in any form of farming or ranching? Required	Yes No
Do you conduct any business or give private lessons in your home? (e.g. daycare, office, Avon, etc.) Required	Yes No
Type of business Optional
Has your mortgage company changed? Required	Yes No
Is this home unoccupied or being rented to others? Required	Yes No
Do you have any of the following? Optional	Swimming pool Diving board Trampoline
Do you have any pets? Required	Yes No
Type/breed Optional
Would you like an estimate of your home's replacement cost at today's prices? Required	Yes No
Would you be interested in an umbrella policy that extends your auto and home liability coverage to $1 million or more? Required	Yes No
Do we write your auto insurance? Required	Yes No
If not, can we give you a quote? Optional	Yes No
What month does your current policy expire? Optional
Do you have any of the following? Optional	Wood burning stove Traditional fireplace Freestanding fireplace
Additional comments Optional
Submission Validation Required	Enter the Validation Code from above.

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.