CPR Questionaire

Please fully complete this form. It helps us to prepare your competitively-priced insurance proposal.

Personal Info

*First Name:
*Last Name:
*Primary Phone:
*E-Mail Address:
*Best Time to Contact:
*Contact Preferences:

Automobile Questions

Renewal Date:
Is every vehicle on your policy titled to at least 1 of the named insured's on the policy?
Are you paid by someone to run errands, pick up and/or provide delivery service with an auto on your personal auto policy?
Do you use any of the vehicles on your personal auto policy in any business matter other than farming or ranching; even on a limited or part-time basis?
Have you changed the usage of your auto and not told us of that change?
Have you and your spouse retired since your auto and not told us of that change?
Do you pull a camper or any type of trailer with any of the vehicles listed on your policy?
Do you have any customized features including outside painting or attached equipment to any vehicle listed on your personal auto policy? This equipment would include but not be limited to, a snow plow, salt spreader, camper body, truck cap, dump body, or any inside customizing features?
Would you like to review all the credit options available under your auto policy and take advantage of all discounts?
Do you travel outside the U S, its territories and possessions, Puerto Rico, or Canada and rent autos?
Is there a company vehicle in the household?
Do you have a motorcycle, snowmobile, ATV, golf cart, or segway?
Should any of the Loss Payees, Lien holders, or Additional Insured's be removed from your policy?
Would you like to discuss and review the different coverages, limits and deductibles available under your auto policy?

Homeowners Questions

Renewal Date:
Please verify that ALL deeded owners of the property are listed on the policy.
Do you have a wood, pellet, corn, kerosene, or coal stove?
Is your stove, pipe and chimney cleaned every year?
Have you added to your residence at a cost or $5000 or more since your coverage was written?
Do you have any unrelated people residing on your property?
Do you own a pool?
Do you own any dogs or horses?
Do you have any secondary, seasonal, or rental properties including lots other than your home?
Do you provide any baby-sitting and/or day care services at your residence?
Do you have an in-home business?
Do you have contents at another location?
Do you own any collections, antiques, or fine arts?
Please select any of the following coverages for which you wish additional information.These coverages are not automatically included and need to be endorsed to the homeowners policy.
(Ctrl + Click to select more than one)
Do you have computers, tools, or equipment that are business related at your home?
Do you have domestic employees?: ie: Nanny, gardener, chauffeur, lawn care.
Do you have any children away at college?
Do you own a boat or jet-ski?
Are you aware of the limitations of personal property under your homeowners policy -
jewelry, cash, furs, guns, etc?
Would you like to review your coverage limits and deductible options on your homeowners?

Personal Umbrellas

Renewal Date:
Do have a youthful driver as a resident of your household or do you expect to have one soon?
Do you have any RV's, including motorcycle, boat, ATV, camper, snow mobile, etc?
Any additional properties including rental and/or seasonal?
Does anyone in your household participate in the following - golf, hunting, or target shooting?
Do you have a pool, trampoline, or animals?
Is anyone in your household considered a "Public Person" in your community? (i.e. Coach, instructor, board of directors, member of a civic organization, or own their own business, etc)
Did you know one trip to an attorney for a consultation regarding a claim will cost more than most personal umbrellas?

Life Insurance

Do you have coverage other than employer provided?
Have you increased financial obligations - purchased a new home, or had a child since this coverage was effective?
Is there coverage for you, your spouse, and your children?

Disability Insurance

Renewal Date:
Do you have disability coverage - this is not work comp., which provides coverage only when you are injured on the job?

Health Insurance

Renewal Date:
Do you own your own business?
Does your employer provide health insurance for you?

Are there any other questions or concerns we have not addressed in this questionnaire?


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