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YES
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NO
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Do you own any antiques, fine arts, collections or other special value items such as tamps or Coins?
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Do you own any jewelry or furs valued at over $1000 which are not specifically insured?
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Would you like us to send a form to assist in making an inventory of your personal property?
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Do you own seasonal property anywhere in New Hampshire? Outside New Hampshire? (please circle)
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Do you maintain an office in your home - or give private lessons, such as music lessons?
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Do you want a costimator to help determine what it would cost to rebuild your home at today's prices?
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Do you plan to buy or sell any property within the next 12 months?
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Do you live in an area that could be flooded?
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Do you have a smoke detector or burglar alarm system? (please circle)
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Do you or anyone in your household smoke? (If not, you may qualify for a non-smoker's credit)
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Would you like to review the current limits and other coverages on your vehicles?
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If your car was damaged, is it important to have a substitute car furnished for your use?
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Do you have a stereo in your vehicle, not factory installed?
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Do you own a boat? If so, what horsepower?________ Length_______ Sail______ Power_______
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Do you own any camping, travel trailers, motor homes, motorcycles, ATV's or golf carts? (please circle)
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Do you plan to travel by plane within the next 12 months on a business or personal trip?
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Would you be interested in discussing life insurance, retirement plans or health insurance?
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Would you be interested in discussing mutual fund investment or Individual Retirement Accounts (IRAs)?
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Would you be interested in discussing disability income insurance in case you are sick or hurt?
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Would you be interested in receiving a quote on mortgage cancellation insurance in the event of premature death, disability or accelerated mortgage payoff?
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Would you be interested in discussing personal umbrella liability insurance, which would give you increased liability limits and protection above your homeowners and auto policy coverage? (see enclosed brochure)
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Would you be interested in a quote on earthquake coverage?
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Are you involved in any business ownership or professional practice? Please describe briefly:
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Name __________________________________________________________
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Type of business __________________________________________________
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Address ________________________________________________________
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Position ________________________________________________________
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Is there anything that we can do for you in connection with any of your insurance programs or other services we offer?
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Do you have any general comments about our staff, services, products, etc? _______________________________________________________________
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