Personal Insurance Review Form

First Name *

Last Name *

ZIP / Postal Code *

Best Time to Contact Monday to Friday 8:30am to 5:00pm *

Primary Phone Number *

E-Mail Address *

Spouse Information

Spouse First Name

Spouse Last Name

Protecting Other People

This section refers to those individuals involved in an accident that is your fault and you are held responsible to pay for or replace damaged property and/or pay for medical bills.

Let’s say you are driving to work tomorrow and had an accident and you were at fault. If there were $300,000 in damages and medical bills would you want this entire amount paid?

Yes
No
I have a question on this

If someone were seriously injured in the accident and sued you for $1,000,000 would you want your insurance to pay the full amount?

Yes
No
I have a question about this

Do you own any of the following?

Hold down the Ctrl Key to make multiple selections.

Did You Know… More than 75% of trampoline accidents happen with more than one person on the trampoline?

Do you have any income producing hobbies?

Yes
No
I have a question about this

Did You Know… Dog attacks on humans, including those which have resulted in deaths, have become more common? If you have a vacant house, or a property without a house or other structures, you could have a problem with your insurance coverage?

Do you have any type of home-based business?

Yes
No
I have a question about this

Do you have any vacant houses or property?

Yes
No
I have a question about this

Protecting Yourself And Your Family

In this section we want to look at areas that will make sure that you preserve the lifestyle for yourself and your family. This includes important areas such as Identity Theft and personal use of cars furnished by employers.

In the event of death would you want the loans on your vehicles or your mortgage paid?

Yes
No
I have a question about this

If you had a chronic illness that left you unable to care for yourself for an extended period of time, where would you want the money to come from to live?

My Policy
Not a concern at this time
Out of my pocket
I have a question about this

Did You Know… A person age 65 today faces a 40% chance of spending time in a nursing home during their lifetime.

If you were involved in an accident that was not your fault but the other driver’s insurance was not able to pay for your loss, would you want the money to come from your insurance policy?

Yes
No
I have a question about this

Does anyone in your household drive a car that is furnished by their employer?

Yes
No
I have a question about this

Your Current Situation

This information will be useful in making certain there has been nothing that has affected your insurance program.

Have you made any improvements or additions to your home over the past year?

Yes
No
I Have a question about this

Have you made any major purchases over the past year?

Yes
No
I Have a question about this

Have you had a change in your marital status?

Yes
No
I have a question about this

Have you had a change in the number of people living at your home?

Yes
No
I have a question about this

Have you added a burglar alarm or other security devices to your home or auto?

Yes
No
I have a question about this

Do you have a wood burning stove?

Yes
No
I have a question about this

Do you do any type of farming?

Yes
No
I have a question about this

Did You Know… Changes to your life could actually lower your cost of insurance or that your auto insurance rate could be affected by a student that is away at college.

Do you have drivers under the age of 21?

Yes
No
I have a question about this

Do you have any drivers away at college?

Yes
No
I have a question about this

Do you ever make purchases over the Internet?

Yes
No

Other Policies

In order to properly protect your assets, it is important that we have complete information about all of your insurance coverage that is not written with us.

Policies you have that are not with us.

Hold down the Ctrl Key to make multiple selections.

Feedback

If any of our team members have provided exceptional service over the past year, please tell us about it.

Questions

Do you have any questions about your insurance program?

Helping Others

Do you know about our referral program? (www.ClubColgrove.com - that rewards you with movie tickets and so much more)

Yes
No, tell me more

Who else do you know that could use our services? We would love to call them and enter you into our referral club.

Thank you for taking the time to complete our Customer Insurance Review form.

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