1.    Would you consider increasing your deductibles to lower your premium?  Yes No

2.    How many vehicles are in your household? 1 2 3 4 5+     Of these vehicles how many do we insure? 1 2 3 4 5+

3.    Are all of the licensed drivers (age 16 & older) and all drivers age 14 or older with a school permit in your household listed on your auto policy? Yes No

4.    Would you like to include your custom installed car stereo, car phone, CB, or two-way radio on your auto policy for an additional premium? Not Applicable Yes No

5.    If you own a pickup of van, does it contain any customized equipment? Not Applicable Yes No

6.    Do you own a pickup camper or other type of RV? Yes No         If so, do we insure it?  Not Applicable Yes No

7.    Do you own a mini-bike, moped, motorcycle, or four-wheeler? Yes No     If so, do we insure it?  Not Applicable Yes No

8.    Do you have vehicles furnished for your regular use that you do not own, such as a company car? Yes No

9.    Do you want rental reimbursement coverage in the event that your car is damaged in an accident? Yes No Already Have It

10.    Would you be interested in increasing your auto liability coverages for only a few dollars per term? Yes No                                                                                                                  Note: We recommend at least $100,000 Bodily Injury per person/$300,000 Bodily Injury per accident/$100,000 Property Damage Liability per accident

11.   If you have a loan or lease on your vehicle, would you be interested in loan/lease payoff coverage?  Yes No No Loan or Lease Already Have It           

12.  If you were in an auto accident, would you like your vehicle to be repaired with Original Equipment Manufacturer (OEM) Parts?  Aftermarket is OK Definitely OEM No Preference

13.  Do you own any antiques, fine arts, silverware, collectibles (coins, stamps, etc.), jewelry, furs, or photography equipment in your home? None of the Following Antiques Fine Arts Silverware Collectibles Jewelry Furs Photography Equipment You may select more than one in the drop down menu by holding down the control key while clicking the option.

14.  Do you have a computer in your home?  Desktop Laptop None of the Above   If so, what is the computer's value? 

15. Do you own any guns in excess of $2500?  Yes No

16. Do you frequently carry or keep in your home more than $200 in cash or other securities?  Yes No

17. Would you be interested in an earthquake endorsement or a flood policy?  Earthquake Endorsement Flood Policy Both Earthquake and Flood Neither

18. Do you have any of the following protective devices in your home?  Fire Extinguisher Smoke Detectors Deadbolt Locks Sprinkler System Fire Alarm Burglar Alarm None of the Above You may select more than one in the drop down menu by holding down the control key while clicking the option.

19. How many square feet is your home?    (Your homeowner's dwelling limit should be square footage multiplied by 110.)

20. Do you own any other property or secondary residences (farms, lake homes, cabins, etc.)?  Yes No   If so, in what state is the real property located? 

21. Are you presently engaged in any activities such as farming or ranching? Yes No

22. Do you conduct any business out of your home or provide private lessons?  Yes No

23. Do you offer child care out of your home on a regular basis?  Yes No

24. Do you own any boats, watercraft, or other recreational vehicles such as golf carts, 4-wheelers, Gators, or snowmobiles?  Yes No

25. Would you be interested in an Umbrella policy that provides for Excess Liability that extends your Auto and Homeowner's Liability Limits? Yes No Already Have One

26. Do you own any professional tools, equipment, or keep a large amount of other's business property in your home or auto?  Yes No

27. Does your home have a swimming pool, hot tub, or a trampoline?  Pool Hot Tub Trampoline None of the Above You may select more than one in the drop down menu by holding down the control key while clicking the option.

28.  Do you own a dog? Yes No     If so, what breed of dog (s) do you have? 

29. Do you own any exotic pets (iguanas, snakes, etc.) Yes No   If so, specify breed and type of pet

30. Would you be interested in Identity Theft Coverage? Yes No

31. Would you like for your insurance payments to be deducted electronically from a checking or savings account or a debit/credit card?  Yes No Already setup on EFT

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Thank you for taking the time to complete the above questionnaire.  Your responses will help us analyze your homeowners and/or automobile policies to ensure that you are protected as adequately as possible.  Upon reviewing your results, one of our licensed agents would like the opportunity to sit down with you and discuss your current coverages, and provide you with any recommendations.  Although valuable, completing this form does not obligate you to visit in person with our agents.

Please note that coverage changes cannot be bound via telephone voice mail or via electronic media.  You must speak to one of our licensed agents directly.

Thank you for being our customer.