Home & Auto Renewal Questionnaire "*" indicates required fields Today's Date* MM slash DD slash YYYY Client Name*Please Enter the name listed first on your insurance policies First Last Are you married?*YesNoSpouse's Full Name* Mailing Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mobile Phone:*Text Messages*Please let us know if you approve contact via text messageYes - ApprovedNo - Do Not TextEmail Address*Please Provide Us With Your Best and Preferred Email Address Preferred Method of Contact*TextPhoneEmailAcknowledgementsAcceptance of Coverage*Your input is ESSENTIAL in our attempt to eliminate gaps in your insurance coverage. Please accept that you have reviewed your current and existing insurance policy(ies) and accept the coverages you currently have. This checklist is used prior to the renewal of your insurance policy(ies) for the purpose of verifying your coverage is up to date. This checklist does not cover every situation, but is a starting point to prompt you to consider major items and questions. Yes I accept Acknowledgement of Truth and Good Faith*I hereby certify that all statements included in the checklist are true and correct to the best of my knowledge. I understand that any false statements may lead to claims being denied, premiums to be adjusted, and/or policies ultimately canceled. Yes, I certify the following answers to be true What Insurance Products Do You Currently Have With My Insurance Group?* Personal Auto Renters Homeowners Landlord Flood Personal Umbrella Boat Recreational Vehicle/Motorcycle Life Insurance Commercial General Questions that may impact insurance (Check all that may apply to you or members of your household) Had a baby Got Married or Engaged Got separated or divorced Purchased a secondary home or investment property Someone moved in or out of your household (including child) Auto Policy ReviewDrivers*Please List All Household Members Over The Age of 15 and provide Date of Birth. We will cross reference this list with the list we have on file to ensure accuracy. How Many Vehicles Do You Currently Own?*For the purpose of this review, we would like to know about your private passenger automobiles. 123456More Than 6Vehicle 1* Year Make and Model Annual Miles Driven Principal Operator Vehicle 2* Year Make and Model Annual Miles Driven Principal Operator Vehicle 3* Year Make and Model Annual Miles Driven Principal Operator Vehicle 4* Year Make and Model Annual Miles Driven Principal Operator Vehicle 5* Year Make and Model Annual Miles Driven Principal Operator Vehicle 6* Year Make and Model Annual Miles Driven Principal Operator Additional Vehicles*Please Provide the Details of All Other Vehicles Not Previously ListedCustom Equipment*Do any of your vehicles have custom equipment? Ex. stereo systems, after market parts or grill guards, custom rims, performance accessories, etc. NoYesIf Yes, Please Describe:*Please specify that equipment, it's value, and which vehicle it has been added to.Do any of the drivers listed on the policy work from home?*You may be eligible for a discount if you work from home. No Yes If Yes, Please Describe*Please list which driver works from home and how many days per week they work from home. Do you have a company car furnished to you that you park at your home and use on a regular basis?* No Yes Delivery*Do you or any drivers listed on the policy use any vehicles listed on the policy for delivery for hire, such as Doordash, Uber Eats, Shipt, etc... No Yes Please Describe Any Deliveries*Ridesharing*Are any vehicles on the policy used for transportation for hire, such as Uber or Lyft? Yes No Please list the vehicle(s) used for Rideshare*Glass Coverage*The average windshield replacement is $400. Would you like a lower deductible for glass in the event your windshield gets a crack or shattered? Yes No Accident and Minor Violation Forgiveness*Most carriers have packages to forgive accidents and minor violations such as speeding tickets to prevent an increase at renewal. Are you interested in this endorsement? Yes No Original Equipment Manufacturer (OEM)*In the event of accident, carriers have the right to use aftermarket parts to repair your vehicles. Are you open to an OEM endorsement to guarantee manufacturer's original parts? Yes No Driver Telematics (Pay how you drive)*Our clients save 18% annually when completing carrier telematics generally within 90 days. Are you interested? By the way, you can opt out so don't be nervous. Yes No Payment Discounts*Insureds who pay in full can save up to 10%. Are you interested? Yes No Personal Umbrella*A personal umbrella provides additional liability in the event of a major accident or personal injury. Have you considered an umbrella? Yes No Do you have any additional questions, concerns, or feedback regarding your auto insurance policy?* Yes No Please Describe your Questions, Concerns, or Provide Any Feedback.* Renters PolicyPlease review the personal property limit on your renters policy. Do you feel this limit is adequate to replace all the "stuff" in your apartment?*YesNoWhat should the limit be?* HomeownersPurchased Property?*Have you bought or sold a house, vacation property, farm, vacant land since your last insurance review?NoYesIf Yes, Please DescribeMortgage Company*Have there been any recent changes in your mortgage company information? Does anyone, except a mortgagee, have financial interest in your home? Do you have a second mortgage or home equity line of credit?Home - Outbuildings*Do you have any outbuildings or detached structures from the home that need to be insured? (Shop, shed, detached garages, carports, awnings, etc)NoYesIf Yes, Please provide a brief description of the structures.*Home - Updates and Improvements*Have there been any additions or updates to your home? Ex pool, solar panels, remodeling, additions, updates to the water, heating, plumbing, electrical or roofNoYesIf Yes, Please provide a value and description for all improvements*Dwelling Coverage*Due to accelerated building/construction cost, are you concerned the replacement cost for your home may be insufficient?NoYesFlood Insurance*According to the National Flood Program, 40% of flood claims occur outside a hazardous flood zone. Would you like a flood quote?NoYesHome Sharing*Do you rent your home as part of a home-sharing/renting program like AirBnb, VRBO or other? NoYes Home & Apartment QuestionsHome Business*Do you have any hobbies or conduct any business from you home that grosses more than $2,000 per year? *There are limitations and exclusions for businesses at home, in your garage or renting out space to others for business purposes.NoYesIf yes, Please describe home based business operations*Valuable Items / Scheduled Personal Property*Do you have valuable items such as guns, fine arts, silverware, collectibles, jewelry, sporting equipment, or musical instruments that need to be scheduled? *Many policies have limitations to the coverages available for these items, unless they are scheduled.NoYesIf Yes, Please give a description of the item(s) and a value*Home and Apartment Safety / Smart Features* Monitored Burglar Alarm Monitored Fire Alarm Fire Alarm / Smoke Detectors Fire Extinguisher Smart Water Leak Detector Smart Thermostat Security Cameras Do you have any pets?*We realize that people add pets to their household families and these can have implications with regards to your insurance. YesNoPlease describe the number, type, and breed of pets (if dogs)* Finally...Do you have ANY other insurance outside of My Insurance Group?*For us to do a complete job in making sure you are protected, we need to be aware of any additional policies or assets you may have purchased to ensure there are no gaps in coverage. Yes No Please Describe*Do you have any other insurance needs we can address?* Personal Umbrella Auto Homeowners Life Insurance Landlord or Rental Properties Flood Boat or Personal Watercraft Motorcycle or ATV Farm or Agriculture Business/Commercial None at this time Who else do you know we may be able to help?Name First Last PhoneEmail FeedbackDo you have any feedback for us? Is there an area we can improve your experience? Is there a team member you'd like to give kudos to for their effort?Please check if you would like to have a phone conversation with a member of our team to discuss anything at all.If you check this box, you will be sent a link to schedule a time to have a phone conversation with a member of our team. Yes, I would like to receive a call CAPTCHA
