"*" indicates required fields Step 1 of 7 - Contact information 14% URLThis field is for validation purposes and should be left unchanged.Annual Review QuestionnaireName* First Last Email* Life UpdatesChange of address, recent or upcoming?* Yes No New Address* Street Address City 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 State ZIP Code Change of marital status, recent or upcoming?* Yes No Any new kids in the family?* Yes No Anyone work out of a home office?* Yes No Anyone in household self-employed full- or part-time?* Yes No Is anyone working for you on a full- or part-time basis?* Yes No Hire anyone to work in your home such as a nanny, a housekeeper, a caregiver, etc?* Yes No Auto Insurance UpdatesAny new drivers in your household?* Yes No Any vehicles have customized equipment or modifications?* Yes No Recent vehicle loan payoff or lease buyout?* Yes No Any vehicle used for any business purposes?* Yes No Use a company vehicle that you don’t own?* Yes No Does anyone not listed as a driver on your policy use your vehicle(s) regularly?* Yes No Auto Discounts and SavingsYou or your spouse/partner have an auto policy elsewhere?* Yes No Consider increasing your deductible to lower your premium?* Yes No Any vehicless have smart safety technology (Ex: blind spot warning, automatic emergency braking)?* Yes No Are you AAA members?* Yes No Low annual mileage on any of your vehicle(s)?* Yes No Estimated annual mileage for each vehicle:A student on your policy lives away at school at a distance of 100+ miles without a vehicle?* Yes No A student on your policy has a grade average of “B” or 3.0 or higher?* Yes No A senior driver has completed an approved advanced driver training program?* Yes No Open to a telematics driving app? Discounts can be up to 30%. Yes No Common auto coverage optionsLet us know if you would like more information about any of the following (check all that apply):* Towing/Roadside Assistance Coverage Rental car reimbursement coverage Auto loan/lease gap coverage New vehicle replacement value coverage Accident forgiveness Minor violation forgiveness Disappearing deductible / deductible waiver OEM parts (ex: Chevy repaired with original Chevy parts instead of aftermarket) No interest in any *Coverage options vary by insurance company, qualifying restrictions and limitations apply; additional coverage options may be available Home Insurance UpdatesMade any home improvements that you haven’t informed us of?*Ex: new roof, remodeling, additions Yes No Describe the improvements made (Year completed, type of improvement, materials used, approximate cost, etc.)*Consider increasing your deductible to lower your premium?* Yes No Business property stored at your residence or in your vehicle?* Yes No Have a second home or investment property home?* Yes No Rent all or a portion of any properties that you own?* Yes No Have any valuable jewelry, guns, collectibles, etc. that we have not discussed?* Yes No Home is in a legal trust?* Yes No Recently paid off your mortgage?* Yes No Common Homeowners Coverage NeedsLet us know if you would like more information about any of the following (check all that apply):* Open Peril Contents coverage Water Backup/Sump Overflow coverage Underground Service Line coverage Equipment Breakdown coverage Hidden Water Damage coverage Ordinance or Law coverage Personal Injury coverage Home Business coverage Identity Theft coverage Personal Cyber coverage No interest in any *Coverage options vary by insurance company, qualifying restrictions and limitations apply; additional coverage options may be available Additional Coverage NeedsOwn any of the following "toys" (check all that apply)?* None Owned Campers/RVs Motorcycles/Moped Boats/Jetskis Golfcarts ATVs Drones eBikes Snowmobiles Other Additional Coverage Needs*Let us know if you would like more information about any of the following (check all that apply): Personal Umbrella Liability policy Earthquake insurance Flood insurance Business insurance Life insurance No interest in any Feedback - we value your input!How would you rate the service that our agency provides?What can we improve or provide to make your experience with us even better?
