Eagle Rock Insurance_11-0080-00_Auto Renewal Review Form

Auto Renewal Review Form

Eagle Rock Insurance
PERSONAL INFORMATION:
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number

Area Code Phone Number
Email
example@example.com
Does your policy declarations page correctly list: Your Legal Names, Mailing and Garaging Address?

Yes No
Describe:
Does your agency insure all your vehicles?

Yes No
Is the vehicle usage correct?

Yes No
Any vehicles listed on your policy not titled in your name?

Yes No
Any of your vehicles garaged at another residence/address?

Yes No
Do you use your vehicles to deliver goods or carry passengers for a fee?

Yes No
Does your auto policy list the names of all drivers in your home?

Yes No
Do you routinely use vehicles you do not own?

Yes No
Is any vehicle you own being used by someone who does not live with you?

Yes No
Are you interested in Towing & Rental Car coverage or Lease/Gap Coverage?

Yes No
Do we carry your homeowners insurance?

Yes No
If not, can we quote you?

Yes No
FINANCIAL:
Would you like a complimentary retirement cash flow analysis?

Yes No
Would you like a complimentary Social Security benefits analysis?

Yes No
Would you like a complimentary review of the tax impact of your current retirement income strategy?

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:
Enter the message as it's shown *
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.
Should be Empty: