Annual Personal Risk Evaluation First name What is your first name?
Last name What is your last name?
Preferred Phone Number What is your preferred phone number?
Email What is your email address?
Annual Evaluation Customization* A thorough evaluation entails completing each of the sections listed below. However, if there is a section that is not applicable it can be removed from this form by unchecking the box.
Home Review Let's start with your home
Location? Provide a description for your home.
(Example: Arizona home, New York condo)
Alarm System Did you install an alarm system in this home in the last 12 months?
Alarm components Which components are included in your alarm system?
Other Alarm Components What other components are part of your alarm system? (enter a description)
Risk Management What risk management strategies do you employ at this residence?
Risk Mitigation Other What are the other risk mitigation strategies you have at this home?
Trust / LLC Is your home owned by a trust, LLC or other legal entity?
Entity name Please provide the name of the trust, LLC or other legal entity your home is owned by.
Renovations Any updates/renovations/additions planned or recently completed?
About renovations Please tell us about the updates/renovations/additions.
Home updates Have you updated any of these?
Location 1 Occupancy Has the occupancy status of your home changed?
Occupancy changed How has the occupancy of your home changed?
Occupancy other* Other (Please describe the occupancy of this home.)
Flood insurance Would you like to discuss obtaining new flood coverage or higher flood insurance limits for your home?
Would you like a quote for increased fungi or mold coverage above the amount provided by your policy? Would you like a quote for increased fungi or mold coverage above the amount provided by your policy?
Would you like a quote to add or increase coverage for personal cyber protection? Would you like a quote to add or increase coverage for personal cyber protection?
Home business Any business conducted at this home?
Business description Please tell us about your in-home business.
Do you have life insurance? Do you have life insurance?
Would you like us to provide you with a proposal for life insurance? Would you like us to provide you with a proposal for life insurance?
Would you like us to review your current policy or provide a proposal for an alternative solution? (Please select the applicable choice below) Would you like us to review your current policy or provide a proposal for an alternative solution? (Please select the applicable choice below)
Please upload a copy of your current life insurance policy for us to review, if available. Please upload a copy of your current life insurance policy for us to review, if available.
What is the coverage limit you would like a quote for? What is the coverage limit you would like a quote for?
Select $1,000,000 $500,000 $250,000 $100,000 Other Amount
Enter your desired coverage limit: Enter your desired coverage limit:
What is your desired policy term? What is your desired policy term?
10 Years 15 Years 20 Years 25 Years 30 Years Permanent/Whole Life
Please select your gender. Please select your gender.
Height Please enter your height.
Weight Please enter your weight.
Have you been diagnosed with or treated for any medical condition within the past 10 years? Have you been diagnosed with or treated for any medical condition within the past 10 years?
Has any immediate family member been diagnosed with heart disease, stroke or cancer before age 60? Has any immediate family member been diagnosed with heart disease, stroke or cancer before age 60?
Have you used tobacco products within the past 12 months? Have you used tobacco products within the past 12 months?
Please list all medications and reasons for taking: Please list all medications and reasons for taking:
Anything else? Anything else you want to discuss regarding your homeowners insurance for this home?
Secondary Home Review Let's review another home.
2nd home description Provide a description for this home. (Ex. Florida home)
Alarm system 2nd home Did you install an alarm system in the last 12 months in this home?
Alarm System Components 2nd Home Which components are included in your alarm system?
Other Alarm System Components What other alarm system components do you have?
Risk Management Strategies 2nd Home What risk management strategies do you employ at this home?
Other Risk Management Strategies 2nd Home* What other risk management strategies do you employ at this home?
Trust or LLC 2nd Home* Is this home owned by a trust, LLC or other legal entity?
Trust or LLC 2nd Home Name* What is the legal spelling of the trust, LLC or legal entity
Renovations 2nd Home* Any updates/renovations/additions planned or completed for this home?
Renovations 2nd Home Description* Tell us about the updates/renovations/additions.
Home Updates 2nd Home* Have you updated any of these? (Select all that apply)
Home Occupancy 2nd Home* Has the occupancy status of this home changed?
Home Occupancy Status 2nd Home* How has the occupancy status of this home changed?
Other Occupancy Status 2nd Home Description* Please describe the occupancy of this home?
In-home Business 2nd Home* Any business conducted at this home?
In-home Business 2nd Home Description* Tell us about your in-home business.
Would you like a quote for increased fungi or mold coverage above the amount provided by your policy? Would you like a quote for increased fungi or mold coverage above the amount provided by your policy?
Flood Coverage 2nd Home* Would you like to discuss adding Flood insurance for this home?
Anything Else 2nd Home? Any thing else you want to discuss regarding your insurance for this home?
Valuables Articles Review Let's review your valuable articles coverage
Valuables acquired?* Any significant acquisitions in the past 12 months that we should know about?
Acquisition description Please provide a brief description of the item(s) you purchased/acquired?
Appraisals Do you have any new appraisals for your valuables that you can upload to us?
Appraisal upload Do you have any new appraisals for your valuable articles?
Bank vault?* Are any of your valuable items stored in a bank vault?
Valuables risk management strategies Select the risk management strategies you use to protect your valuable articles.
Other valuables risk management strategies Provide a brief description of the other risk management strategies you use to protect your valuable articles?
Valuables Trust or LLC? Are any of your valuable articles owned in a trust or LLC?
Valuables Trust or LLC Name* Please describe the property owned in the trust or LLC and provide the name of the entity.
Valuables anything else? Is there anything else you would like to discuss regarding your valuable articles? (ex. loaning to a museum or repairs being done)
Automobile Review Let's review your automobile coverage.
Have you purchased any vehicles in the past 12 months? Have you purchased any vehicles in the past 12 months?
New Car Description Please enter the year, make and model of the vehicle(s) you purchased.
Have you sold or turned in any vehicles in the past 12 months? Have you sold or turned in any vehicles in the past 12 months?
Car(s) sold or turned in Description Please enter the year, make and model of the vehicle(s) you sold or turned in.
New drivers? Any new drivers to be added to your policy?
New Driver Info Please provide the new driver information.
Drivers away at school? Any drivers away at school without a car?
School and Driver Name Please enter the name and address of the school as well as the student's name.
Good Student? Please select the option that best describes the student's grade point average.
Report Card Upload If available, please upload a copy of the student's report card.
Car loans? Have you paid off any car loans?
Cars paid off Which car(s) did you pay off?
Auto business use? Are any of your cars used for business purposes? (Including ride sharing services such as Uber and Lyft.)
Business use description Provide a brief description of the car and the business it is being used in.
Auto anything else? Is there anything else you would like to discuss regarding automobile insurance?
Life Review Do you have life insurance? Do you have life insurance?
Would you like us to provide you with a proposal for life insurance? Would you like us to provide you with a proposal for life insurance?
Would you like us to review your current policy or provide a proposal for an alternative solution? (Please select the applicable choice below) Would you like us to review your current policy or provide a proposal for an alternative solution? (Please select the applicable choice below)
Please upload a copy of your current life insurance policy for us to review, if available. Please upload a copy of your current life insurance policy for us to review, if available.
What is the coverage limit you would like a quote for? What is the coverage limit you would like a quote for?
Select $1,000,000 $500,000 $250,000 $100,000 Other Amount
Enter your desired coverage limit: Enter your desired coverage limit:
What is your desired policy term? What is your desired policy term?
10 Years 15 Years 20 Years 25 Years 30 Years Permanent/Whole Life
Please select your gender. Please select your gender.
Height Please enter your height.
Weight Please enter your weight.
Have you been diagnosed with or treated for any medical condition within the past 10 years? Have you been diagnosed with or treated for any medical condition within the past 10 years?
Has any immediate family member been diagnosed with heart disease, stroke or cancer before age 60? Has any immediate family member been diagnosed with heart disease, stroke or cancer before age 60?
Have you used tobacco products within the past 12 months? Have you used tobacco products within the past 12 months?
Please list all medications and reasons for taking: Please list all medications and reasons for taking:
Liability Review Let's review your liability exposures.
Net worth? What is your approximate net worth?
Liability risks Tell us about your liability risks? (Select all that apply)
Other liability risks Please provide a brief description of your other liability risk(s).
Liability anything else Is there anything else you would like to discuss regarding your liability protection?
Additional Discussion Topics Other Topics What other topics should we discuss?
Other other areas Provide a brief description of the other area you would like to discuss.
Consent* Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
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