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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
Have you done any remodeling, add-ons, outbuilding additions, etc.?
Required

Is yes, please list
Optional
Do you employ anyone in your home, such as a housekeeper, babysitter, or gardener?
Required

Do you own any boats, jet skis, or other watercraft?
Required

Do you own any snowmobiles, golf carts, or other recreational vehicles?
Required

Do you have any of the following items that you would like to schedule?
Optional





Are you interested in any of the following coverages?
Optional



Are you interested in water/sewer backup?
Optional


Do you presently have the following in your home?
Optional


Do you have a security system for your home?
Optional


Do you own a second home or any other real property, such as a cabin, farm property or any income producing property?
Required

Are you presently engaged in any form of farming or ranching?
Required

Do you conduct any business or give private lessons in your home? (e.g. daycare, office, Avon, etc.)
Required

Type of business
Optional
Has your mortgage company changed?
Required

Is this home unoccupied or being rented to others?
Required

Do you have any of the following?
Optional


Do you have any pets?
Required

Type/breed
Optional
Would you like an estimate of your home's replacement cost at today's prices?
Required

Would you be interested in an umbrella policy that extends your auto and home liability coverage to $1 million or more?
Required

Do we write your auto insurance?
Required

If not, can we give you a quote?
Optional

What month does your current policy expire?
Optional
Do you have any of the following?
Optional


Additional comments
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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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