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 ---YesNo Would you consider increasing your deductibles to lower your premiums? ---YesNo Do we currently insure all the vehicles in your household?If not, how many do you insure elsewhere? ---YesNo Are all of the licensed drivers in your household listed on your auto policy? ---YesNo 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? ---YesNo If you own a pickup or a van, does it contain any customized equipment? ---YesNo Do you own a pickup camper unit or camper shell? ---YesNo Do you own minibikes, mopeds, or motorcycles?If so, how many? ---YesNo Do you have vehicles furnished for your regular use that you do not own, such as a company car?If so, how many? ---YesNo Do you want Rental Reimbursement coverage in the event that your car is damaged in an accident? ---YesNo Do you own any boats, motorbikes, motor homes, or other recreational vehicles, such as snowmobiles or golf carts? Homeowners/Renters/Condos ---YesNo Do you own any antiques, fine arts, silverware, or collections such as unique dishes, figurines, and so on? ---YesNo Do you own any jewelry? ---YesNo Do you own any furs? ---YesNo Do you own any valuable camera equipment? ---YesNo Do you frequently carry, or keep in your own, more than $100 in cash? ---YesNo Do you have a coin or stamp collection? ---YesNo Do you own any guns? ---YesNo Would you prefer to cover your personal belongings for their full replacement value, i.e., no deduction for depreciation? ---YesNo Would you be interested in adding earthquake or flood insurance to your homeowner protection? ---YesNo Do you currently have either a burglar, fire or smoke alarm in your home? ---YesNo Would you like an estimate of your home's replacement cost at today's prices? ---YesNo Do you own a second home or any other real property, such as a cabin, farm property, or any income-producing property? ---YesNo Are you currently engaged in any form of farming or ranching? ---YesNo Do you conduct any business or give private lessons in your home? ---YesNo 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 ---YesNo Do you have Disability Income insurance in case you become sick or disabled? ---YesNo Are you concerned about estate taxes? ---YesNo Do you have Mortgage Redemption insurance policy, which pays off your house in the event of your death? ---YesNo Are all members of your family protected by Life Insurance? ---YesNo Would you like a review of the beneficiaries, ownership, and cash values (if any) of your Life insurance policies? ---YesNo Do you have a retirement or pension plan? ---YesNo Are you self-employed? If so, have you heard about Keogh retirement plans, and would you like to know more? ---YesNo Are you aware that Accidental Death and Disability insurance for you and your family is available at low cost? ---YesNo Is your Heath insurance up to date? ---YesNo Are you interested in discussing Life insurance within the next year? ---YesNo If you are a self-employed professional, would you like a quotation for your Property Liability and Professional Liability or Malpractice insurance? ---YesNo Have you been purchasing an IRA? Would you like to meet and review all of your protection? Please call us or stop by.