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Quick Insurance Checkup
First Name
*
Last Name
*
Phone
*
Email
*
Which type of insurance do you have with us? Select all that apply.
*
Personal Insurance
Business Insurance
Personal Insurance
Preferred Method of Contact
Phone
Email
What concerns do you have about your insurance?
General Life Changes
The following life events can impact all your insurance policies. Please select all that apply.
Had a baby
Got married or engaged
Separated or got divorced
Purchased an investment property
Someone moved into or out of your household (including a child)
Your child turned 18
Home Discount Checklist
The following discounts may apply to your home, condo, or renters insurance policy, even if your alarms are self-monitored (such as with Nest Protect or SimpliSafe). Please select all that apply.
Fire alarm
Burglar alarm
Gas alarm (such as a carbon monoxide alarm or automatic gas main shut-off)
Water alarm (such as a water leak sensor or automatic water shut-off)
Non-smoker
Life Changes That Impact Home Insurance
The following life changes may impact your home, condo, or renters insurance policy. Please select all that apply.
Completed a home remodel, improvement, or addition
Purchased or inherited high value items like jewelry, firearms, or artwork
Purchased an outdoor trampoline
Began renting out your home, either on a long term or short-term basis (like Airbnb)
Started a home based business or have a hobby that earns income
Serve on the board of a nonprofit, including a homeowners association
Adopted a pet
Vehicle Usage
Your insurance company may have new discounts available based on your vehicle usage. Please provide the following for each car you own:
Pleasure or Commute?
Commute Distance one-way (if applicable)
Annual Miles Driven
Auto Discount Checklist
The following discounts may apply to your auto policy. Please select all that apply.
Driver safety course completion (age 55+)
AAA member
Child good student discount (3.0 GPA or higher)
Child away at college (75+ miles from or more) without a car
Low mileage (8,000 miles a year or less)
Life Changes that Impact Auto Insurance
The following life changes may impact your auto policy. Please select all that apply.
Recently paid off a loan or lease for one of your cars
Have (or will have!) a teen driver
Changed jobs or retired
Drive for work, such as for real estate agent or pizza delivery
Began driving for Uber, Lyft, Amazon Flex, or a similar company
Purchased an ATV, motorcycle, or other motorized vehicle
We're always striving to improve. We welcome a few words of feedback if there's anything we can do to better serve you. Thank you!
Business Insurance
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Are there any business properties or pieces of equipment that you have recently acquired, leased, or sold?
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No
Have you closed or opened any business locations?
Yes
No
Has your company building undergone any renovations, additions, or other significant changes?
Yes
No
Have you added, changed, or removed any company products?
Yes
No
Has your inventory level experienced any significant shifts or fluctuations?
Yes
No
Do you either purchase supplies from or sell your products to foreign countries?
Yes
No
Has the ownership structure of your business changed?
Yes
No
Has there been a 10% or greater change in your business's revenue in the last year?
Yes
No
Do 50% or more of your materials come from a single supplier?
Yes
No
Do 50% or more of your sales come from a single buyer?
Yes
No
Do any of your employees regularly work from home or from another state?
Yes
No
Do any of your employees regularly travel to other states or countries for business?
Yes
No
Do any of your employees travel for business in their personal vehicles?
Yes
No
Has your company leased, purchased, or sold any automobiles or other vehicles?
Yes
No
Do you require all vendors, subcontractors, and 1099 workers to provide certificates of insurance?
Yes
No
Are there any other insurance coverage issues you would like to discuss today?
Yes
No
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