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Life Changes Simple Survey
Home
Life Changes Simple Survey
Life Changes Simple Survey
Joe
2023-10-09T12:20:08-04:00
Life Changes Simple Survey
Your Name
(Required)
First
Last
Preferred Phone Number
(Required)
Preferred Email
(Required)
Has Your Mailing Address Changed
(Required)
Yes
No
Correct Mailing Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Have You Had Any Life Changes Since Your Last Renewal
(Required)
Yes
No
Please let us know about life changes such as: * New child * Employment change * New driver/ teen driver in the household * Acquired or sold any vehicles (including RV, trailer, boat, motorcycle) * Purchased or sold real estate * Created a living trust
Tell Us About Your Life Changes
Has Your Marital Status Changed
(Required)
Yes
No
Please Provide Details
Do You Own a Business
(Required)
Yes
No
What Type of Business Do You Own
Have You Earned a Degree or Certification Since Your Last Renewal
(Required)
Yes
No
Type of Degree or Certification
Have Your Driving Habits Changed
(Required)
Yes
No
If you were commuting to work, but now work from home you could receive an additional discount. Are you using your car for work (Uber driver, contractor going from site to site, realtor, etc) and/or are you advertising for your business on your vehicle? These factors could have extra exposure and coverage concerns that we would want to advise you on to ensure you are properly protected.
Tell Us About Any Changes In Driving Habits
(Required)
Would You Like to Save up to 40% by Bundling your Home and Auto?
(Required)
Yes
No
I Already Bundle
Bundling your Home & Auto can save you up to 40%. Simply select Yes to see how much money you can save.
Would You Like a Quote for Flood Insurance
(Required)
Yes
No
I Already Have Flood Insurance
Flood is EXCLUDED on all home insurance policies. 25% of flood losses happen in low risk flood areas.
Have You Completed Any Home Improvements to Your Home
(Required)
Yes
No
N/A
New roof, kitchen/bathroom upgrades, electrical upgrades, additional square footage, etc...
When Was the Last Time You Replaced Your Roof?
(Required)
Tell Us About Your Home Improvements
(Required)
Do You Have Any Special Personal Property or Items of High Value
(Required)
Yes
No
I Already Have A Special Personal Property Policy
Items such as jewelry, weapons, fine arts, fur coats, musical equipment, fine china, high-end bicycles may require special coverage to protect you against theft, breakage or mysterious disappearance. Would you like a quote to provide coverage for special personal property? Most homeowner policies limit coverage on these categories to $1,500 - $2,500 TOTAL per category.
List the Items and Approximate Value
(Required)
Would You Like a Quote For an Umbrella Policy (Additional Personal Liability Coverage)
(Required)
Yes
No
Already Have One
Personal Umbrella Liability Coverage is sometimes referred to as lawsuit coverage and helps to protect your assets in the event that someone tries to sue you for bodily injury, property damage and even personal injury. $1M of Personal Umbrella protection can cost as little as $250/year. Our agency HIGHLY RECOMMENDS that you consider this important and inexpensive coverage.
Are You Interested In Receiving An Affordable Life Insurance Quote
(Required)
Yes
No
Already Have One
Do you have Life Insurance outside of your employer? Many times this Life Insurance does not follow you if you leave the job. This small and simple action can leave a lasting legacy and financial protection for your family when you pass away.
Are you interested in reviewing Health Insurance Options
(Required)
Yes
No
Even if you're currently insured, its worth having a review of your current coverages/costs We can help with Individual Major Medical Medicare Short Term Injury Dental/Vision Group Health Sharing Ministries Limited Medical
Additional Items to Insure
(Required)
RV
Boat/Jet Ski
Motorcycle
ATV
Rental Property
Vacation Home
Other
Great! Let Us Know What We Can Quote For You
(Required)
Is There Anything Else We Should Be Aware of As Your Renewal Approaches
Documents to Upload if Needed
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