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 and return the questionnaire in the enclosed envelope.
Name: _________________________________________________________________
Address: _______________________________________________________________
City: ________________________________ State:______________ ZIP:___________
Home Phone: ______________________ Business Phone: ________________________
Date: __________________________________________________________________
AUTOMOBILE/VEHICLE
| YES | NO | |
| | | 1. Would you consider increasing your deductibles to lower your premium? |
| | | 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 Automobile policy? |
| | | 4. Would you like to include your car stereo (if mounted under the dash), tapes, CB, or two-way radio on your Automobile 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
| YES | NO | |
| | | *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.Furs? |
| | | 4.Valuable camera equipment? |
| | | 5.Do you frequently carry, or keep in your home, 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 Homeowners 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 an Umbrella or Excess Liability policy that extends your Automobile and Homeowners Liability coverage to $1 million or more? |
*Coverage for questions 1-7 may be limited or excluded under your policy.
OTHER PERSONAL INSURANCE
| YES | NO | |
| | | 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 a 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 Health insurance up to date? (Consider recent increases in hospital rates.) |
| | | 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.