Kayleen Anderson Schedule a Call! Home & Auto Renewal Questionnaire "*" indicates required fields Step 1 of 9 11% This field is hidden when viewing the formFor AgentToday's Date* MM slash DD slash YYYY Client Name*Please Enter the name listed first on your insurance policies First Last Mobile Phone:*Text Messages*Please let us know if you approve contact via text messageYes - ApprovedNo - Do Not TextEmail Address*Please Provide Us With Your Best and Preferred Email Address Preferred Method of Contact*TextPhoneEmail AcknowledgementsAcceptance of Coverage*Your input is ESSENTIAL in our attempt to eliminate gaps in your insurance coverage. Please accept that you have reviewed your current and existing insurance policy(ies) and accept the coverages you currently have. This checklist is used prior to the renewal of your insurance policy(ies) for the purpose of verifying your coverage is up to date. This checklist does not cover every situation, but is a starting point to prompt you to consider major items and questions. Yes I accept Acknowledgement of Truth and Good Faith*I hereby certify that all statements included in the checklist are true and correct to the best of my knowledge. I understand that any false statements may lead to claims being denied, premiums to be adjusted, and/or policies ultimately canceled. Yes, I certify the following answers to be true What Personal Insurance Products Do You Currently Have With Pinnacle Insurance Agency?* Personal Auto Renters Homeowners Personal Umbrella Boat Recreational Vehicle/Motorcycle Life Insurance General Life Changes that may impact insurance (Check all that may apply to you or members of your household) Had a baby Got Married or Engaged Got separated or divorced Purchased a secondary home or investment property Someone moved in or out of your household (including children or parents) Auto Policy ReviewDrivers*Please List All Household Members Over The Age of 15 and provide Date of Birth. We will cross reference this list with the list we have on file to ensure accuracy. Do any of the drivers listed on the policy work from home?*You may be eligible for a discount if you work from home. No Yes If Yes, Please Describe*Please list which driver works from home and how many days per week they work from home. Auto Insurance Discounts (check those that may apply to you or members of your household)*** Not all discounts are available with all carriers. Each carrier has different discounts Drivers Safety Course Completion (Age 55+) Good Student Discount (3.0 GPA or higher) Child away at college (75+ miles away or more) without a car Do you have any additional questions, concerns, or feedback regarding your auto insurance policy?* Yes No Please Describe your Questions, Concerns, or Provide Any Feedback.* Renters PolicyPlease review the personal property limit on your renters policy. Do you feel this limit is adequate to replace all the "stuff" in your apartment?*YesNoWhat should the limit be?* HomeownersPurchased Property?*Have you bought or sold a house, vacation property, farm, vacant land since your last insurance review?NoYesIf Yes, Please DescribeMortgage Company*Have there been any recent changes in your mortgage company information? Does anyone, except a mortgagee, have financial interest in your home? Do you have a second mortgage or home equity line of credit?Home - Updates and Improvements*Have there been any additions or updates to your home? Ex. remodeling, improvements, additions, updates to the water, heating, plumbing, electrical or roof? *Is the amount of insurance on your home less than it would take to rebuild it?NoYesIf Yes, Please provide a value and description for all improvements* Home & Apartment QuestionsWhat year was your roof replaced or installed?*Do you have any of the following:* Sump Pump Battery Backup Sump Pump Water Intrusion Alarm None Home and Apartment Safety / Smart Features* Monitored Alarm Security Cameras None Finally...Do you have ANY other insurance outside of Pinnacle Insurance Agency?*For us to do a complete job in making sure you are protected, we need to be aware of any additional policies or assets you may have purchased to ensure there are no gaps in coverage. Yes No Please Describe*Do you have any other insurance or referral needs we can address (we have great referral partners)?* Business Insurance Life Insurance Mortgage broker Realtor None of the Above Who else do you know we may be able to help?One of the greatest compliments anyone can give our agency is to refer us a new customer. Name First Last PhoneEmail Feedback*Do you have any feedback for us? Is there an area we can improve your experience? Is there a team member you'd like to give kudos to for their effort?
