Eagle Rock Insurance_11-0080-00_Home Renewal Review Form

PERSONAL INFORMATION:

Name

First Name Last Name

Email

example@example.com

Primary Phone Number

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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?

Yes No

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?

Yes No

Describe

Do you have any alarms installed in your home?

Yes No

If so, what type?

Do you have children away at college?

Yes No

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

Yes No

If so, what type?

Is your basement finished?

Yes No

If yes, what percentage?

Do you own a business or plan to start one?

Yes No

Do you operate an office or studio in your home?

Yes No

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

Yes No

Do you have any domestic employees?

Yes No

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

Yes No

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

Yes No

Do you have in-home day care?

Yes No

Do you have a dog, cat or other pet?

Yes No

If so, what breed?

Any bite history?

Yes No

Do you use a wood-burning stove?

Yes No

Do you have a swimming pool?

Yes No

If so, is it fenced?

Yes No

Diving Board?

Yes No

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

Yes No

Do you belong to a Homeowners Association?

Yes No

Do we carry your auto insurance?

Yes No

If not, can we quote you?

Yes No

Interested in:

Water back up or quote to increase current coverage Identity Theft Coverage Flood Insurance

FINANCIAL:

Would you be interested in a complimentary financial plan review?

Yes No

Review of your existing investment portfolio?

Yes No

Analysis of your retirement funding methods?

Yes No

Social Security benefit analysis?

Yes No

Educational funding strategies?

Yes No

MISCELLANEOUS:

Do you own any of the following recreational vehicles?

Boat/Jet Ski Motorcycle Golf Cart All Terrain Vehicles Motor-home Camper Moped Snowmobile Other

If others, please list:

OPTIONAL COVERAGES:

Are you interested in:

Identity Theft Flood Insurance Umbrella Policy Life Insurance Disability Insurance

Comments/Notes:

VERIFICATION CODE:

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