Annual Personal Risk Evaluation
What is your first name?
What is your last name?
What is your preferred phone number?
What is your email address?
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
Provide a description for your home.
(Example: Arizona home, New York condo)
Did you install an alarm system in this home in the last 12 months?
Which components are included in your alarm system?
What other components are part of your alarm system? (enter a description)
What risk management strategies do you employ at this residence?
What are the other risk mitigation strategies you have at this home?
Is your home owned by a trust, LLC or other legal entity?
Please provide the name of the trust, LLC or other legal entity your home is owned by.
Any updates/renovations/additions planned or recently completed?
Please tell us about the updates/renovations/additions.
Have you updated any of these?
Has the occupancy status of your home changed?
How has the occupancy of your home changed?
Other (Please describe the occupancy of this home.)
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 to add or increase coverage for personal cyber protection?
Any business conducted at this home?
Please tell us about your in-home business.
Do you have 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)
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?
Enter your desired coverage limit:
What is your desired policy term?
Please select your gender.
Please enter your height.
Please enter your weight.
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?
Have you used tobacco products within the past 12 months?
Please list all medications and reasons for taking:
Anything else you want to discuss regarding your homeowners insurance for this home?
Secondary Home Review
Let's review another home.
Provide a description for this home. (Ex. Florida home)
Did you install an alarm system in the last 12 months in this home?
Which components are included in your alarm system?
What other alarm system components do you have?
What risk management strategies do you employ at this home?
What other risk management strategies do you employ at this home?
Is this home owned by a trust, LLC or other legal entity?
What is the legal spelling of the trust, LLC or legal entity
Any updates/renovations/additions planned or completed for this home?
Tell us about the updates/renovations/additions.
Have you updated any of these? (Select all that apply)
Has the occupancy status of this home changed?
How has the occupancy status of this home changed?
Please describe the occupancy of this home?
Any business conducted at this home?
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 to discuss adding Flood insurance for this home?
Any thing else you want to discuss regarding your insurance for this home?
Valuables Articles Review
Let's review your valuable articles coverage
Any significant acquisitions in the past 12 months that we should know about?
Please provide a brief description of the item(s) you purchased/acquired?
Do you have any new appraisals for your valuables that you can upload to us?
Do you have any new appraisals for your valuable articles?
Are any of your valuable items stored in a bank vault?
Select the risk management strategies you use to protect your valuable articles.
Provide a brief description of the other risk management strategies you use to protect your valuable articles?
Are any of your valuable articles owned in a trust or LLC?
Please describe the property owned in the trust or LLC and provide the name of the entity.
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?
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?
Please enter the year, make and model of the vehicle(s) you sold or turned in.
Any new drivers to be added to your policy?
Please provide the new driver information.
Any drivers away at school without a car?
Please enter the name and address of the school as well as the student's name.
Please select the option that best describes the student's grade point average.
If available, please upload a copy of the student's report card.
Have you paid off any car loans?
Which car(s) did you pay off?
Are any of your cars used for business purposes? (Including ride sharing services such as Uber and Lyft.)
Provide a brief description of the car and the business it is being used in.
Is there anything else you would like to discuss regarding automobile insurance?
Life Review
Do you have 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)
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?
Enter your desired coverage limit:
What is your desired policy term?
Please select your gender.
Please enter your height.
Please enter your weight.
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?
Have you used tobacco products within the past 12 months?
Please list all medications and reasons for taking:
Liability Review
Let's review your liability exposures.
What is your approximate net worth?
Tell us about your liability risks? (Select all that apply)
Please provide a brief description of your other liability risk(s).
Is there anything else you would like to discuss regarding your liability protection?
Additional Discussion Topics
What other topics should we discuss?
Provide a brief description of the other area you would like to discuss.
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.
