Personal Protection Review

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1Contact Update

2Auto Update

3Home Update

4Recreational Update

5Rental Update

6General Update

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AMS Link

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Google Drive URL

First Name*

Last Name*

Cell Phone*

Email*

Employer

Current Job Position

Street Address*

City*

State*

Zip Code*

Spouse / Partner Info

Spouse First Name

Spouse Last Name

Spouse Cell Phone

Spouse Email

Spouse Employer

Spouse Job Position

Communication Preference

Best contact for servicing:*

Spouse/Partner

Both of Us

Communication Preference:*

Text & Email (I'm not good with checking email)

Email Only (I check my junk/spam folder)

Never Contact Me (I understand I will not receive critical policy information)

Has there been any change in employment?*

My Spouse

Both Me and My Spouse

No Change

Auto Updates

Do you have an Auto Policy with our Agency?*

Yes

Auto Policy

If you were involved in an accident that was not your fault but the other driver's didn't have insurance or their insurance was not able to pay the whole amount, would you prefer your insurance to pay instead?*

I prefer that my insurance to pay for damages caused by someone else if their insurance wouldn't pay

No, I prefer to pay for this out of my personal savings

One of the main reasons we have auto insurance is to protect ourselves financially in case we damage other's property or injure them. With increasing costs to replace or repair cars and medical care, are you interested in increasing the liability limits you have on your policy?*

Yes, I am interested in having higher liability limits.

No, I'm happy with where my coverage limits are.

Regarding damage to your car, would you rather have a lower deductible for less out-of-pocket in the event of a claim or would you prefer to lower your monthly premiums by choosing a higher deductible and keep more money in your pocket?*

I prefer Lower Monthly Payment & Higher Deductible

I prefer Higher Monthly Payment & Lower Deductible

Let's say you had a broken or cracked windshield from a rock as you drove down the road, would you prefer to pay for the glass damage out-of-pocket or would you prefer to have your insurance take care of it?*

I prefer to pay for glass claims out of pocket

I prefer to pay higher premiums and have glass covered

Have you installed any aftermarket equipment on your auto(s)?*

Aftermarket equipment includes any parts, accessories, or modifications added to your vehicle that were not installed by the original manufacturer. This may include: custom wheels/rims, specialty sound systems, DVD players, custom lighting, body kits, wraps/custom paint, window tint, lift kits, performance modifications, truck bed covers/caps, custom interiors, or any other permanent additions to the vehicle.

Yes, I do have some aftermarket equipment on my auto(s)

No, I do not have any aftermarket equipment on my auto(s)

How many licensed or permitted drivers are living in your household?*

Are any vehicles used for ride sharing activities (Uber or Lyft etc)?*

Yes, I do drive for a ride sharing company

No, I do not drive for a ride sharing company

Does anyone in the household use a vehicle for business purposes or delivery?*

Yes, I do use my vehicle for business or delivery.

No, I do not use my vehicle for business or delivery.

Does anyone in the household have a vehicle provided by an employer?*

Yes, I do have a company provided vehicle

No, I do not have a vehicle provided by my company

Do you have a young driver(s) that is eligible for the Good Student Discount (3.0 or above)?*

Yes

Do you have a child no longer living with you or attending school over 100 miles away without a car?*

Child has moved out

Child attending school over 100 miles away without a car

No Change

Are there any New or will there be any new licensed drivers in the household this year that are not currently disclosed on your auto insurance?*

No Change - All licensed drivers are listed on my auto insurance

Need to add a recently licensed driver to our policy

Will have a new licensed driver this coming year

Other

Have you acquired a new vehicle that has not been added to your policy yet?*

No Change - All vehicles are listed on our policy correctly

Yes, I need to add a new vehicle to our policy

I need to remove a vehicle that I no longer own

Auto Update Additional Details

Home Update

Do you have a Home policy with our Agency?*

Yes

Home Policy

Regarding damage to your home, would you rather have a lower deductible for less out of pocket in the event of a claim or would you prefer to lower your monthly premiums by choosing a higher deductible?*

I prefer Lower Monthly Premium & Higher Deductible

I prefer Higher Monthly Premium & Lower Deductible

We have seen increases in home values and construction costs. Would you like to review the coverage for your home and make sure it is covered for replacement cost?*

Yes, I would like to review this

No, I am happy with my current level of coverage

Most homeowners insurance policies exclude coverage in the case of sewer or drain backup and your carpet was ruined or other damage to your home. You can include on your policy for an extra cost. Would you like a quote to add this to your policy?*

Yes, I prefer damage caused by a drain backup to be covered

No, I do not want this coverage on my policy

Most homeowners insurance policies exclude coverage in the case of an earthquake. Sometimes you can include on your policy for an extra cost or you can get a separate policy to cover that. Would you like a quote to add this coverage?*

Yes, I prefer earthquake damage to be covered by insurance

No, I do not want this coverage on my policy

Most homeowners insurance policies exclude coverage in the case of a flood, which means water coming from outside of the home into the home. You can get a separate policy to cover that. Would you like a quote to add this coverage?*

Yes, I prefer flood damage covered by insurance

No, I do not want this coverage on my policy

Do you have any Jewelry, Antiques, Collectibles, Guns, or Fine Arts that need to be scheduled on your policy?*

Yes, I do have some added items that need to be scheduled

No Changes - no new items needing to be scheduled.

Have you made any improvements or additions to your home? (Check All That Apply)*

Roof Replaced

Furnace Replaced

A/C Replaced

Water Heater Only

Complete Plumbing Update

Electrical Panel Only

Complete Electrical Update

Solar Panels

Other

No Updates, Improvements, or additions

Are the Solar Panels owned or leased?

Owned Solar Panels

Leased Solar Panels

How many solar panels?

What was the cost of the solar panels?

Do you have trampoline, swimming pool or pets? (Check All That Apply)*

Pets

Trampoline

Swimming Pool

No Pets, Trampoline or Swimming pool

Do you have an active burglar alarm or other security device monitored by a security company?*

No Fire and/or Theft Monitoring

Fire & Theft Monitoring

Fire Monitoring Only

Theft Monitoring Only

Do you have any of the following Smart Connected Devices? (Select All that Apply)*

No Smart Devices

Smart Camera

Smart Smoke Alarm

Smart Lights

Automatic Temperature Detection

Water Leakage Detection / Automatic Shut-Off

Gas Leakage Detection / Automatic Shut-Off

We recommend having an inventory of your personal belongings. Do you have an inventory of all your household possessions?*

Yes, I do have an inventory of our household possessions.

No, I do not have an inventory of our household possessions

Do you rent out any part of your home to others? (Check short term or long term)*

Yes, Short Term Rental

Yes, Long Term Rental

No, no part of our home is rented out

Have you purchased a secondary residence, including a condo or timeshare that is not currently listed on your policy(ies)?*

No secondary residence

Yes, purchased a secondary residence

Home Update Additional Details

Recreational Toys Update

Do you own any Recreational Vehicles not covered on your current policy(ies)? (Check All That Apply)*

None

Antique/Classic Vehicle

ATV / UTV / Side x Side

Motorcycle

Watercraft

RV / Travel Trailer

Recreational Update Additional Details

Rental Property Updates

Do you own any Rental Properties?*

Yes

Do you need to report any change in status, improvements or additions to any rental property? (Check All That Apply)*

Roof Replaced

Furnace Replaced

A/C Replaced

Water Heater Only

Complete Plumbing Update

Electrical Panel Only

Complete Electrical Update

Currently Vacant

No Longer Vacant

Other

No Updates, Improvements, or additions

Rental Update Additional Details

General Update Questions

Have you experienced any major life events in the past year?*

No Changes

Got Married

Got Divorced

Had a Child

Lost a Child

Moved

Have you had a notable change in NetWorth?*

Yes, I have had a notable change in NetWorth.

No, I have NOT had a notable change in NetWorth.

If someone were to sue you for any reason (add up all assets, home, savings, retirement accounts, future income) what range do you think they would try to sue you for?*

1 Million

1 - 2 Million

2 - 3 Million

3 - 4 Million

4 - 5 Million

5 - 10 Million

10 - 15 Million

15 - 20 Million

20+ Million

Have you added or changed ownership of any assets including vehicle titles, Trusts or LLC's?*

Yes, there has been some changes of asset ownership

No, there has not been any change of asset ownership

Trust or LLC Name

Items with Ownership Change

Have you accepted a position on a board(s) of a profit or non-profit organization(s)?*

Yes, I have accepted a position on a board of a profit or non-profit organization(s)

No, I do NOT hold a position on any board(s) of a profit or non-profit organization.

Have you started a home-based business or work from home for your employer?*

Yes, I have a home based business or work from home

No, I do not work from home or have a home based business

Have you hired any domestic help, nanny or housekeeper, either full or part time?*

Yes, I have hired domestic help, nanny or housekeeper

No, I do not have any domestic help

Life Insurance is an important part of your financial plan. Do you have a Life Insurance policy?*

Yes, I would like to review my life insurance

Yes, but I do not need to review it at this time.

No, I do not have life insurance, lets talk

No, I am not interested

Have you made any other major purchases this past year that are not addressed above?*

Yes

General Update Additional Details

Did you know we offer other insurance products as well? Would you like a quote for any of the following types of policies?

Home

Auto

Second Home

Rental Property

Life

Health

Medicare

Disability

Boat

RV / Travel Trailer

Motorcycle / ATV / Side x Side

Supporting Documents File Uploader:

Drop files here or

Max. file size: 128 MB.

Upload any document(s) that we need for your requested change(s). Such as the paid receipt for a home update like a roof, alarm certificate, good student discount, appraisal for Jewelry or collectibles etc.

***We appreciate you taking the time to update your Insurance!

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AMS ID

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Internal Use

Yes

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