Family Risk Questionnaire

We recommend a yearly review of all your insurance policies. This questionnaire makes that review quick and efficient. Please take a moment to answer the questions.
* required fields

Name*:

Address*:

City*: State*: Zip*:

Home Phone*: Business Phone:

Email*:


Automobile/Vehicle

  1. Would you consider increasing your deductibles to lower your premiums?
  2. Do we currently insure all the vehicles in your household?
    If not, how many do you insure elsewhere?
  3. Are all of the licensed drivers in your household listed on your auto policy?
  4. Would you like to include your car stereo (if mounted under the dash), tapes, CB, or two-way radio on your auto policy for an additional premium?
  5. If you own a pickup or a van, does it contain any customized equipment?
  6. Do you own a pickup camper unit or camper shell?
  7. Do you own minibikes, mopeds, or motorcycles?
    If so, how many?
  8. Do you have vehicles furnished for your regular use that you do not own, such as a company car?
    If so, how many?
  9. Do you want Rental Reimbursement coverage in the event that your car is damaged in an accident?
  10. Do you own any boats, motorbikes, motor homes, or other recreational vehicles, such as snowmobiles or golf carts?


Homeowners/Renters/Condos

  1. Do you own any antiques, fine arts, silverware, or collections such as unique dishes, figurines, and so on?
  2. Do you own any jewelry?
  3. Do you own any furs?
  4. Do you own any valuable camera equipment?
  5. Do you frequently carry, or keep in your own, more than $100 in cash?
  6. Do you have a coin or stamp collection?
  7. Do you own any guns?
  8. Would you prefer to cover your personal belongings for their full replacement value, i.e., no deduction for depreciation?
  9. Would you be interested in adding earthquake or flood insurance to your homeowner protection?
  10. Do you currently have either a burglar, fire or smoke alarm in your home?
  11. Would you like an estimate of your home's replacement cost at today's prices?
  12. Do you own a second home or any other real property, such as a cabin, farm property, or any income-producing property?
  13. Are you currently engaged in any form of farming or ranching?
  14. Do you conduct any business or give private lessons in your home?
  15. Would you be interested in a Personal Excess Liability policy that extends your Automobile and Homeowner Liability coverage to $1 million or more?

Coverage for questions 1-7 may be limited or excluded under your policy.


Other Personal Insurance

  1. Do you have Disability Income insurance in case you become sick or disabled?
  2. Are you concerned about estate taxes?
  3. Do you have Mortgage Redemption insurance policy, which pays off your house in the event of your death?
  4. Are all members of your family protected by Life Insurance?
  5. Would you like a review of the beneficiaries, ownership, and cash values (if any) of your Life insurance policies?
  6. Do you have a retirement or pension plan?
  7. Are you self-employed? If so, have you heard about Keogh retirement plans, and would you like to know more?
  8. Are you aware that Accidental Death and Disability insurance for you and your family is available at low cost?
  9. Is your Heath insurance up to date?
  10. Are you interested in discussing Life insurance within the next year?
  11. If you are a self-employed professional, would you like a quotation for your Property Liability and Professional Liability or Malpractice insurance?
  12. Have you been purchasing an IRA?


Would you like to meet and review all of your protection? Please call us or stop by.