Life Changes Simple Survey Date MM slash DD slash YYYY Name(Required) First Last Preferred Phone Number(Required)We want to be sure we have the best way to contact you if needed.Preferred Email(Required) Has your mailing address changed?(Required) Yes No Correct Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal 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(Required)Has your marital status changed?(Required) Yes No Please provide details:(Required)Own a Business?(Required) Yes No What type of business do you own?(Required)Have you earned a degree or certification since your last renewal?(Required) Yes No Higher education can potentially add up to additional savings. This includes college, military MOS training, and vocational certifications (cosmetology school, journeyman/apprenticeship program, trucking school, etc.).Type of Degree or Certification(Required)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.Have you completed any home improvements to you home?(Required) Yes No N/A New roof, kitchen/bathroom upgrades, additional square footage, etc...What year was your roof last replaced?(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 Person 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 and 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.Additional items to insure RV Boat/Jet Ski Motorcycle ATV Rental Property Vacation Home Other Is there anything else we should be aware of as your renewal approaches?Documents to upload if neededMax. file size: 5 MB.
