Insurance Service Center DePere - Personal Information Checklist

Family Information

	Full Name	Email Address (not required for children)	Home Phone	Cell Phone	Employer Name	Occupation	Amount of current life insurance/mortgage insurance (optional):
Insured:
Spouse:
Child 1:
Child 2:
Child 3:
Child 4:

There are various discounts that insurance companies offer. Please check all that apply:
AAA Membership

InsuredSpouse
Do you belong to a Non Profit Organization? If so, type name(s) of organizations below:
Insured's Organizations:
Spouse's Organizations:
Student away from home without a car over 100 miles

Child 1Child 2Child 3Child 4
Good student discount (3.0 GPA or better)

InsuredSpouseChild 1Child 2Child 3Child 4
Do you have a platinum card?

InsuredSpouse
College Graduate

InsuredSpouseChild 1Child 2Child 3Child 4
Member of any professional organization? If yes, which ones?
Insured's Professional Organizations:
Spouse Professional Organizations:
Child 1 Professional Organizations:
Child 2 Professional Organizations:
Child 3 Professional Organizations:
Child 4 Professional Organizations:
Please check any of interest:

Life Insurance401K RolloverMortgage InsuranceDisability InsuranceHealth InsuranceRoth IRAFuneral InsuranceChildren's College Planning
Comments
I have personally reviewed the answers above. I understand that this checklist is not meant to imply, in any manner, that these are the ONLY items that may be of concern to me. I understand it is my responsibility to advise Insurance Service Center of any special circumstances or insurance needs I may have.
Client Signature*
Date*

MonthDayYear
Enter the message as it's shown*
Send to*
Should be Empty: