Evaluation - New Policy

Annual Personal Risk Evaluation

Name*

What is your full name?

Email*

What is your email address?

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?

Yes
No

Alarm components*

Which components are included in your alarm system?

Fire/Smoke
Burglar/Motion
Low Temperature
Water Leak Detection/Automatic shut-off valve
Cellular Backup
Gas Leak Detection
Other

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?

Yes
No

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?

Yes
No

About renovations

Please tell us about the updates/renovations/additions.

Home updates

Have you updated any of these?

Electrical
Plumbing
Heating
Windows and/or doors
Roof
No updates

Occupancy

Has the occupancy status of your home changed?

Yes
No

Occupancy changed*

How has the occupancy of your home changed?

Renting to a long term tenant
Renting to a short term tenant (by the day, week or month)
Unoccupied for greater than 30 days
Unoccupied and for sale
Other

Occupancy other*

Other (Please describe the occupancy of this home.)

Flood insurance

Would you like to discuss obtaining new flood coverage or higher limits for your home?

Yes
No

Home business

Any business conducted at this home?

Yes
No

Business description

Please tell us about your in-home business.

Anything else?

Anything else you want to discuss regarding your homeowners 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?

Jewelry
Fine Art
Silverware
Wine
Antiques
Firearms
Collectibles
Other
None

Acquisition description

Please provide a brief description of the item(s) you purchased/acquired?

Item description	Value ($)

Appraisals

Do you have any new appraisals for your valuables that you can upload to us?

Yes
No

Appraisal upload

Do you have any new appraisals for your valuable articles?

Drop files here or

Max. file size: 128 MB.

Bank vault?*

Are any of your valuable items stored in a bank vault?

Yes
No

Valuables risk management strategies*

Select the risk management strategies you use to protect your valuable articles.

Permanently installed safe at home
Wireless tracking sensors
Alarm system
Other
None

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?

Yes
No

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.

New drivers?*

Any new drivers to be added to your policy?

Yes
No
Not sure, let's discuss

New Driver Info*

Please provide the new driver information.

Name	Date of Birth	License Number	State

Drivers away at school?*

Any drivers away at school without a car?

Yes
No
Soon

School and Driver Name*

Please enter the school and driver name.

Driver name	School name

Car loans?*

Have you paid off any car loans?

Yes
No
Soon

Cars paid off

Which car(s) did you pay off?

Year	Make	Model

Auto business use?*

Are any of your cars used for business purposes? (Including ride sharing services such as Uber and Lyft.)

Yes
No

Business use description*

Provide a brief description of the car and the business it is being used in.

Car	Usage Description

Auto anything else?

Is there anything else you would like to discuss regarding automobile insurance?

Liability Review

Let's review your liability exposures.

Net worth?

What is your approximate net worth?

Up to $1,000,000
$1,000,001 to $5,000,000
$5,000,001 to $10,000,000
Over $10,000,000
Please contact me

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?

Life Events

What else is going on?

Other areas

What other areas should we discuss?

Building a house
Buying/Selling property
Change of marital status
Child going to college
Property held for rental
Starting a business
Planning a big trip
None
Other

Other other areas

Provide a brief description of the other area you would like to discuss.

New Policy

Annual Personal Risk Evaluation

Home Review

Valuables Articles Review

Automobile Review

Liability Review

Life Events

RiskRevu^TM Newsletter

Contact

New Policy

Annual Personal Risk Evaluation

Home Review

Valuables Articles Review

Automobile Review

Liability Review

Life Events

RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter