Eagle Rock Insurance_11-0080-00_Home Renewal Review Form

Home Renewal Review Form

Eagle Rock Insurance
PERSONAL INFORMATION:
Name

First NameLast Name
Email
example@example.com
Primary Phone Number

Area CodePhone Number
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Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your Policy Declarations Page correctly list: Legal names that appear on the deed? Mailing and property address? Mortgage Company name, address and loan number?

YesNo
Do you have particular items to schedule? Collectible, antiques, fine art, stamps, coins, baseball cards, jewelry, furs, firearms, costly sporting equipment, cameras, tools, equipment or instruments?

YesNo
Describe
Do you have any alarms installed in your home?

YesNo
If so, what type?
Do you have children away at college?

YesNo
Any remodeling, additions, alteration to your home in the past 24 months?

YesNo
If so, what type?
Is your basement finished?

YesNo
If yes, what percentage?
Do you own a business or plan to start one?

YesNo
Do you operate an office or studio in your home?

YesNo
If so, do clients come into your home to make purchases?

YesNo
Do you have any domestic employees?

YesNo
Do you rent any part of your home and/or separate structures?

YesNo
Any residents in your household who are not related to you?

YesNo
Do you have in-home day care?

YesNo
Do you have a dog, cat or other pet?

YesNo
If so, what breed?
Any bite history?

YesNo
Do you use a wood-burning stove?

YesNo
Do you have a swimming pool?

YesNo
If so, is it fenced?

YesNo
Diving Board?

YesNo
Do you own rental/investment property, second residence/vacation home (i.e. condo, cabin, or trailer)?

YesNo
Do you belong to a Homeowners Association?

YesNo
Do we carry your auto insurance?

YesNo
If not, can we quote you?

YesNo
Interested in:

Water back up or quote to increase current coverageIdentity Theft CoverageFlood Insurance
FINANCIAL:
Would you like a complimentary retirement cash flow analysis?

YesNo
Would you like a complimentary Social Security benefits analysis?

YesNo
Would you like a complimentary review of the tax impact of your current retirement income strategy?

YesNo
MISCELLANEOUS:
Do you own any of the following recreational vehicles?

Boat/Jet SkiMotorcycleGolf CartAll Terrain VehiclesMotor-homeCamperMopedSnowmobileOther
If others, please list:
OPTIONAL COVERAGES:
Are you interested in:

Identity TheftFlood InsuranceUmbrella PolicyLife InsuranceDisability Insurance
Comments/Notes:
VERIFICATION CODE:
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