Client Name: E-mail: Phone:
Address:
Home Yes / No
Do you have collectibles: antiques, fine arts, stamps, coins, guns etc.? Yes No
Do you have valuable Jewelry? Yes No
Do you have a business in your home? Yes No
Do clients or customers come to your home? Yes No
Do you own professional tools or equipment? Yes No
Do you baby-sit or have child day care in your home? Yes No
Do you own rental or income property? Yes No
Do you have a secondary residence? Yes No
Do you own investment property? Yes No
Have you installed home fire or security alarms? Yes No
Do you own recreational vehicles: boat, jet-ski, camper, cycle etc.? Yes No
Do you own any battery operated kids vehicles? Yes No
Have you remodeled your home? Yes No
Do you have plans to remodel? Yes No
Do you have “umbrella” liability coverage? Yes No
Do you have an above ground or in ground swimming pool? Yes No
Do you have detached structures: gazebos, storage barn? Yes No
Have there been any recent updates to your home? Yes No
Do you have domestic help, babysitters, landscapers, housecleaners? Yes No
Do you have wood burning stove? Yes No
Do you have a fireplace? Yes No
Have you had your chimney professionally cleaned and inspected within the last 12 months? Yes No
Do you have flood insurance? Yes No
Is there or has there ever been evidence of water leakage or seeping in the residence? Yes No
Do you have earthquake insurance? Yes No
Would you like to have identity theft protection with your homeowners policy? Yes No
Have you recently married? Yes No
Have you recently divorced? Yes No
Have you recently had or adopted children? Yes No
Comment:
   
Auto Yes / No
Have you recently bought or sold any vehicles? Yes No
Do you have any new drivers in your household? Yes No
Does anyone outside of your household regularly drive your vehicles? Yes No
Do you have any antique or classic vehicles? Yes No
Do you have any vehicles that are registered, but not insured? Yes No
Do you have any vehicles that are not titled solely to you and/or your spouse? Yes No
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