| First Name
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| Last Name
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| ZIP / Postal Code
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| Best Time to Contact Monday to Friday 8:30am to 5:00pm
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| Primary Phone Number
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| E-Mail Address
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| Spouse Information |
| Spouse First Name
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| Spouse Last Name
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| 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?
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| 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?
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| Do you own any of the following?
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| 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?
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| 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?
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| Do you have any vacant houses or property?
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| 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?
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| 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?
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| 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?
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| Does anyone in your household drive a car that is furnished by their employer?
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| 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?
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| Have you made any major purchases over the past year?
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| Have you had a change in your marital status?
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| Have you had a change in the number of people living at your home?
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| Have you added a burglar alarm or other security devices to your home or auto?
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| Do you have a wood burning stove?
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| Do you do any type of farming?
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| 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?
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| Do you have any drivers away at college?
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| Do you ever make purchases over the Internet?
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| 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.
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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.
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| Questions |
| Do you have any questions about your insurance program?
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| Helping Others |
| Do you know about our referral program? (www.ClubColgrove.com - that rewards you with movie tickets and so much more)
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| Who else do you know that could use our services? We would love to call them and enter you into our referral club.
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| Thank you for taking the time to complete our Customer Insurance Review form. |
| After you submit this form it should take you to a new page that says Thank You for the submission. If nothing happens then one of the required fields above may not be filled in correctly. Please go back and check and then submit again. |
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