YES
NO

2. Have you remodeled or made significant changes to your home?

YES
NO

3. Do you have any “appurtenant structures” (garage, etc) on insured premises?

YES
NO

4. If YES on question 3, Any used for Business purposes?

YES
NO

OR, any rented to others?

YES
NO

5. Do you have a swimming pool?

YES
NO

If YES, Select NONE SELECTED INGROUND ABOVE GROUND

6. Do you have personal property totaling more than the policy automatically provides?

YES
NO

7. Do you have any jewelry, furs, guns, cameras, or collectibles?

YES
NO

8. Do you have exposure to water that backs up through sewers or drains?

YES
NO

9. Do you desire to carry Earthquake coverage?

YES
NO

10. Do you have a wood burning stove, kerosene heater, etc.?

YES
NO

11. Do you have any questions regarding Flood coverage?

YES
NO

12. Do you have any incidental business activities out of your home? (Baby-sitting, Amway, Beauty Shop, Newspaper Delivery or Lawn Care)

YES
NO

13. Do you own any pets? (Kind, Breed, & How Many)

YES
NO

If YES, Kind/Breed/Qty

 

14. If we currently have your home & auto policy, would you be interested in a $1,000,000 liability policy?

YES
NO

15. Do you have any recreational vehicles? (Boat, Motorcycle, Moped, 3-wheeler or snowmobile)

YES
NO

16. Do you serve as an officer or member of the Board of Directors of a non-profit corporation or organization?

YES
NO

17. Are you interested in saving money on your homeowner's insurance if we can write your auto?

YES
NO

18. Do you have any problems, questions or concerns?

YES
NO

            Name:

         Policy #:

        Phone #:

Email Address:

Are you Interested in Identity Theft Coverage: ---please select--- YES NO

               Today's Date: (format: DD/MM/YYYY)