Personal Insurance Wish List

Your Insurance, Your Way: Let’s Begin

Company

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What do you have?

Contact Information

First Name*

Last Name*

Mobile Phone*

Email*

Relationship Status*

Home Address*

Street Address Address Line 2 City State ZIP Code

Employer

Current Job Position

Spouse / Partner Info

Spouse First Name

Spouse Last Name

Spouse Mobile Phone

Spouse Email

Spouse Employer

Spouse Job Position

Communication Preference

Best contact for servicing:*

Spouse/Partner

Both of Us

Communication Preference:*

Text & Email (I’m not good with checking email)

Email Only (I check my junk/spam folder)

Never Contact Me (I understand I will not receive critical policy information)

Auto Insurance Wish List

If you were involved in an accident that was not your fault but the other driver's didn't have insurance or their insurance was not able to pay the whole amount, would you prefer your insurance to pay instead?*

I prefer that my insurance to pay for damages caused by someone else if their insurance wouldn’t pay

No, I prefer to pay for this out of my personal savings

Let's say you were driving to work or the store tomorrow, had an accident, you were at fault, and there was $350,000 in damages – would you want your insurance policy to pay all damages?*

Yes, I would want at least $350,000 damages covered if I were at fault in an accident

No, I would rather pay out of my savings if I were at fault in an accident

Regarding damage to your car, would you rather have a lower deductible for less out-of-pocket in the event of a claim or would you prefer to lower your monthly premiums by choosing a higher deductible and keep more money in your pocket?*

I prefer Lower Monthly Payment & Higher Deductible

I prefer Higher Monthly Payment & Lower Deductible

Let's say you had a broken or cracked windshield from a rock as you drove down the road, would you prefer to pay for the glass damage out-of-pocket or would you prefer to have your insurance take care of it?*

I prefer to pay for glass claims out of pocket and keep my insurance costs lower

I prefer to pay higher premiums and have glass covered

Would you want medical expenses reimbursed for you or a passenger in your car that was injured in an accident whether you were at fault or not?*

Yes, I would want medical expenses reimbursed by my insurance

I would prefer to pay medical from my savings

Have you installed any aftermarket equipment on your auto(s)?*

Yes, I do have some aftermarket equipment on my auto(s)

No, I do not have any aftermarket equipment on my auto(s)

Aftermarket Equipment

How many licensed or permitted drivers are living in your household?

Are any vehicles used for ride sharing activities (Uber or Lyft etc)?*

Yes, I do drive for a ride sharing company

No, I do not drive for a ride sharing company

Which vehicle(s) & driver(s) perform ride sharing activities?*

Does anyone in the household have a vehicle provided by an employer?*

Yes, I do have a company provided vehicle

No, I do not have a vehicle provided by my company

Do you have a young driver(s) that is eligible for the Good Student Discount (3.0 or above)?*

Yes

Who is eligible for the Good Student Discount?

Good Student Documentation Acknologement

I will upload the last semester grade card

I will email the last semester grade card to [email protected]

Do you have a child no longer living with you or attending school over 100 miles away without a car?*

Child has moved out

Child attending school over 100 miles away without a car

Child Status Update

Do you have a car(s) with any of the following Smart Auto Features? (Check All That Apply)*

No Smart Auto Features

Automatic Emergency Braking

Blind Spot Warning

Lane Departure Warning

Are there any New or will there be any new licensed drivers in the household this year that are not currently disclosed on your auto insurance?*

All licensed drivers are listed on my auto insurance

Need to add a recently licensed driver to our policy

Will have a new licensed driver this coming year

Add Driver

Email	Other parties phone number	Where did this happen?	Actions

There are no Drivers.

Have you acquired a vehicle that has not been added to your policy yet?*

All vehicles are listed on our policy correctly

Yes, I need to add a new vehicle to our policy

Add a Vehicle

Year	Make	Model / Trim level	VIN Number	Actions

There are no Vehicles.

Auto Update Additional Details

Home Insurance Wish List

Regarding damage to your home, would you rather have a lower deductible for less out of pocket in the event of a claim or would you prefer to lower your monthly premiums by choosing a higher deductible?*

I prefer Lower My Monthly Premium & Higher Deductible

I prefer to Pay More Each Monthly Premium & Lower Deductible

If your home were damaged or destroyed, would you want the money to replace it at current replacement costs?*

Yes, I prefer to rebuild at current replacement costs.

No, I prefer to pay from my personal savings if my insurance isn’t enough to rebuild at current replacement costs.

If you had a sewer or drain backup and your carpet was ruined or cause other damage, would you want it replaced?*

Yes, I prefer damage caused by a sewer or drain backup to be covered

No, I prefer to pay from my personal savings for sewer or drain backup damage

Let's say there was an earthquake that caused a crack in your home's foundation, would you want it covered by your policy?*

Yes, I prefer earthquake damage to be covered by insurance

No, I prefer to pay out of my personal savings for earthquake damage

During a heavy thunderstorm, water collects faster than it can run off and it finds its way into your home causing damage, would you want it covered by Insurance?*

Yes, I prefer flood damage covered by insurance

No, I prefer to pay out of my personal savings for any flood damage

Has there been any improvements or additions to your home? (Check All That Apply)*

Date Roof Replaced

Roofing Material

Other Updates

Are the Solar Panels owned or leased?

Owned Solar Panels

Leased Solar Panels

How many solar panels?

Cost of the solar panels?

Do you have trampoline, swimming pool or pets? (Check All That Apply)*

No Pets, Trampoline or Swimming pool

Pets

Trampoline

Swimming Pool

Do you have an active burglar alarm or other security device monitored by a security company?*

No Fire and/or Theft Monitoring

Fire & Theft Monitoring

Fire Monitoring Only

Theft Monitoring Only

Do you have any of the following Smart Connected Devices? (Select All that Apply)*

No Smart Devices

Smart Camera

Smart Smoke Alarm

Smart Lights

Automatic Temperature Detection

Water Leakage Detection / Automatic Shut-Off

Gas Leakage Detection / Automatic Shut-Off

Do you have an inventory of all your household possessions?*

Yes, I do have an inventory of our household possessions.

No, I do not have an inventory of our household possessions

Any properties used for home-sharing (Airbnb, VBRO etc.)?*

Yes, we list a property(s) for home-sharing usage

No properties are used for home-sharing activities

Have you purchased a secondary residence, including a condo or timeshare that is not currently listed on your policy(ies)?*

No secondary residence

Yes, purchased a secondary residence

Home Update Additional Details

Valuable Items Insurance Wish List

Do you have any jewelry you would want replaced if it were lost on vacation?*

Yes, I would want my jewelry replaced

No, I’m not concerned about replacing my jewelry

Do you have any new Jewelry, Antiques, Collectibles, Guns, or Fine Arts that need to be scheduled on your policy?*

Yes, I do have some added items that need to be scheduled

No Changes – no new items needing to be scheduled.

Scheduled Items

Item Type	Item Description	Item Value	Actions

There are no Scheduled Items.

Recreational Insurance Wish List

Do you have a new atv, motorcycle, boat, rv, travel trailer or classic car that needs to be added to your protection program? on your policy?

Yes, I do have some recreational vehicles that need to be updated

No Changes – no new items at this time

What Recreational Vehicles do we need to add or update? (Check All That Apply)*

Antique/Classic Vehicle

ATV / UTV

Golf Cart

Motorcycle

RV / Motorhome / Travel Trailer

Watercraft

Other

Motorcycle

Motorcycle #1: Year	Motorcycle #1: Make	Motorcycle #1: Model	Motorcycle #1: VIN #	Actions

There are no Motorcycles.

RV / Motorhome / Travel Trailer

Year	Make	Model / Trim level	VIN Number	Actions

There are no Campers.

Watercraft Update

Watercraft

Watercraft Style	Year	Make	Model	Actions

There are no Watercrafts.

Other Recreational Vehicles

Please provide details on the recreational vehicles we need to add or update:

Rental Property Insurance Wish List

Do you own any Rental Properties?*

Yes

Has there been any improvements or additions to any rental property? (Check All That Apply)*

Rental Update Additional Details

General Questions

Have you experienced any major life events in the past year?*

Got Married

Got Divorced

Had a Child

Lost a Child

Moved

No Changes

Have you had a notable change in NetWorth?*

Yes, I have had a notable change in NetWorth.

No, I have NOT had a notable change in NetWorth.

If someone were to sue you for any reason (add up all assets, home, savings, retirement accounts, future income) what range do you think they would try to sue you for?*

1 Million

1 – 2 Million

2 – 3 Million

3 – 4 Million

4 – 5 Million

5 – 10 Million

10 – 15 Million

15 – 20 Million

20+ Million

Have you added or changed ownership of any assets including vehicle titles, Trusts or LLC's?*

Yes, there has been some changes of asset ownership

No, there has not been any change of asset ownership

Trust or LLC Name

Items with Ownership Change

Have you accepted a position on a board(s) of a profit or non-profit organization(s)?*

Yes, I have accepted a position on a board of a profit or non-profit organization(s)

No, I do NOT hold a position on any board(s) of a profit or non-profit organization.

Have you started a home-based business or work from home for your employer?*

Yes, I have a home based business or work from home

No, I do not work from home or have a home based business

Home Based Business or Work From Home Details:

Do you have any income producing hobbies?*

Yes, I do have a hobby that produces some income

No, I do not have any income producing hobbies

Hobby Details

Have you hired any domestic help, nanny or housekeeper, either full or part time?*

Yes, I have hired domestic help, nanny or housekeeper

No, I do not have any domestic help

Let's say you were involved in an accident in your car, or someone hurt themselves on your property, and you were sued for $1,000,000. Where would you want the money to come from?*

Insurance Policy

Personal Assets & Savings

Let's say you were diagnosed with a chronic illness or disability that left you unable to work and earn an income, Where would you want the money to come from?*

I would prefer it to come from an Insurance policy

I have enough in my personal savings to survive

In the event of death, would you want the mortgage on your home and/or loans on your autos paid?*

Yes, I would prefer to have them paid by insurance

No, I am not concerned about this

Do you have a Life Insurance policy that needs to be reviewed?*

Yes, I would like to review my life insurance

No, I am not concerned about this

Have you made any other major purchases this past year that are not addressed above?*

Yes

General Update Additional Details

Supporting Documents File Uploader:

Upload any document(s) that we need for your requested change(s). Such as the paid receipt for a home update like a roof, alarm certificate, good student discount, appraisal for Jewelry or collectibles etc.

Drop files here or

Max. file size: 128 MB.