Personal Insurance Questionnaire

Our agency prides itself on properly managing our client's total risk, therefore we believe that being properly insured is just as important as cost: if we don't know your exposure, we can't make recommendations on coverage. These are very general questions - if you don't know, use your best guess! This should only take you 5 minutes and we will get back to you within 24 hours with additional questions.

First Name

Last Name

Cell Phone

Names, Dates of Birth, and Drivers License Numbers for all drivers in the home

Estimated value of your home?

Current Address

New Address (if a new purchase)

Year, Make, Model, & VIN for all vehicles

Do you have any valuables such as art and Jewelry over $2,500 that you want covered? If so please include an item description and value

Estimated value of toys (boats, snowmobiles, aircraft, ATV/UTV, motorcycles, etc):*

* If you desire coverage for the items above, please provide Year, Make, Model and Serial number/Vin number

Approximate age of your home's roof

Life Insurance: How much benefit do your currently have and how much do you need?

Do you have any pets? If yes, what breed?

Do you own a business and/ or are you on any board of directors?

Date you need your new policy to go into effect? (closing date, upcoming renewal date, etc.)

Please attach your current declarations page.