*Name:
Date:
*Address:
City, State, Zip:
*Home Phone:
*E-mail:
Business Ph:
Fax: ------- Time to call:

1. Would you consider increasing your deductibles to lower your premium?
[Yes ] [No ]
2. Do we currently insure all of the vehicles in your household?
[Yes ] [No ]
If not, how many do you insure elsewhere?
3. Are all of the licensed drivers in your household listed on your auto policy?
[Yes ] [No ]
4. Would you like to include your car stereo (if mounted under the dash), tapes, CB, or two-way radio on your auto policy for an additional premium?
[Yes ] [No ]
5. If you own a pickup or a van, does it contain any customized equipment?
[Yes ] [No ]
6. Do you own a pickup camper unit or camper shell?
[Yes ] [No ]
7. Do you own minibikes, mopeds or motorcycles?
[Yes ] [No ]
If so, how many?
8. Do you have vehicles furnished for your regular use that you do not own, such as a company car?:
[Yes ] [No ]
If so, how many?:
9. Do you want rental reimbursement or towing & labor coverage in the event that your car is damaged in an accident?
[Yes ] [No ]
10. Do you own any boats, motorbikes, motor homes, or other recreational vehicles, such as snowmobiles or golf carts?
[Yes ] [No ]
11. Would you like a quote for higher limits of liability insurance or personal injury protection?
[Yes ] [No ]
12. Do you have other electronic devices you wish to cover (e.g., car phone)?
[Yes ] [No ]

1. Do you own any antiques, fine arts, or collections such as unique dishes, figurines, and so on?
[Yes ] [No ]
2. Do you own any jewelry or furs?:
[Yes ] [No ]
If so, what is the total appraised value of such items?:
3. Do you own valuable camera equipment, silverware, or guns?
[Yes ] [No ]
4. Do you frequently carry or keep in your home more than $100 in cash?
[Yes ] [No ]
5. Do you have a coin or stamp collection?
[Yes ] [No ]
6. Would you prefer to cover your personal belongings for their full replacement value (i.e. no deduction for depreciation)?
[Yes ] [No ]
7. Would you be interested in adding earthquake** or flood insurance to your homeowners protection?
[Yes ] [No ]
8. Do you currently have a burglar, fire or smoke alarm?:
[Yes ] [No ]
Fire extinguishers?
[Yes ] [No ]
Dead bolts on all doors in your home?
[Yes ] [No ]
9. Would you like an estimate of your home's replacement cost at today's prices?
[Yes ] [No ]
10. Would you like home replacement guarantee protection?
[Yes ] [No ]
11. Do you own a second home or any other real property, such as a cabin, farm property, or any income- producing property?
[Yes ] [No ]
12. Are you currently engaged in any form of farming or ranching?
[Yes ] [No ]
13. Do you conduct any business (including childcare) or give private lessons in your home?
[Yes ] [No ]
14. Would you be interested in an umbrella or excess liability policy that extends your auto and homeowners liability coverage to $1 million or more?
[Yes ] [No ]
15. Do you own a computer?
[Yes ] [No ]
For business?
[Yes ] [No ]
For pleasure?
[Yes ] [No ]

1. Do you have disability income insurance in case you become sick or disabled?
[Yes ] [No ]
2. Are you aware that accidental death and disability insurance for you and your family is available at low cost?
[Yes ] [No ]
3. Are you concerned about estate taxes?
[Yes ] [No ]
4. Do you have a mortgage redemption insurance policy (which pays off your house in the event of your death)?
[Yes ] [No ]
5. Are all members of your family protected by life insurance?
[Yes ] [No ]
6. Would you like a review of the beneficiaries, ownership, and cash values (if any) of your life insurance policies?
[Yes ] [No ]
7. Are you interested in discussing life insurance within the next year?
[Yes ] [No ]
8. Do you have a retirement or pension plan?
[Yes ] [No ]
9. Are you self-employed? [Yes ] [No ]
If so, have you heard about Keogh retirement plans and would you like to know more? [Yes ] [No ]
10. Is your health insurance up to date? (Consider recent increases in hospital rates.)
[Yes ] [No ]
11. If you are a self-employed professional, would you like a quotation for business property, professional liability or malpractice insurance?
[Yes ] [No ]
12. Have you been contributing to an IRA (standard or Roth)?
[Yes ] [No ]
13. Are you interested in other financial services?
[Yes ] [No ]

* Coverage for questions 1 to 5 may be limited or excluded under your policy. **Not available in all areas.