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Personal Insurance
Program Questionnaire

This form is designed to provide us with information to update your file, and also to provide you with the offer to quote coverage we presently do not carry for you.

HOMEOWNER COVERAGE (Complete if we currently write)

	Yes	No
Have you made, or do you plan to make, any structural additions to your home, seasonal home or rental dwellings that you have not already informed us of (such as finished basement, added central air or deck, etc.)? If so, please provide specific information:

Do you conduct any business (including childcare) or give lessons in your home? If yes, please provide specific information:

Do you own any boats, snowmobiles, all-terrain vehicles, golf carts, etc., that you currently do not insure? If so, please list:

Have you added any detached structures?

Increased limits of liability may be available and may only result in a small premium increase. Are you interested in higher property and/or liability limits? (We would be happy to assist you with your own determination of the values you decide to insure.)

Increasing your deductibles may be an option and could result in a premium savings. Are you interested in higher deductible options?

Have you acquired or sold a secondary house or rental property?

AUTOMOBILE COVERAGE (Complete if we currently write)

	Yes	No
Are there any new licensed drivers or new household members since the last renewal? List the vehicles owned/non-owned or leased by all resident drivers:

Is any vehicle equipped with non-factory installed equipment, including stereo equipment, grill guards, running boards, camper topper or any item that may be considered customizing? If so, describe by providing year, make and model and what customizing is included:

Does any driver use a vehicle in their job or occupation other than to and from work? If yes, please provide specific information:

Increased limits of liability may be available and may only result in a small premium increase. Are you interested in higher liability limits?

Increasing your deductibles may be an option and could result in a premium savings. Are you interested in higher deductible options?

Are you interested in towing & labor or rental car coverage in the event your car is damaged in an accident?

Is a vehicle furnished for your regular use that you do not own, such as a company car? If so, how many?

PERSONAL LINES COVERAGE

* If we do not write any of the following coverage for you, please indicate if you are interested in a quotation *
	Quote Desired

Automobile covers cars, vans or pickups

Homeowner covers owner-occupied dwellings

Motorhome covers homes on wheels

Umbrella/Personal Excess more fully protects assets from lawsuits for $1,000,000 Excess Liability or more

Personal Articles Floater covers jewelry, furs, fine arts, guns, collectibles and items of rarity, limited by other policies such as homeowners

Flood covers overflow of inland, tidal waters or mudflows, backup of sewers and drains as a result of a flooding condition

Earthquake/Mold under your homeowners policy — coverage covers the dwelling

Fire Dwelling covers one- to four-family rental properties

Renters covers personal property and liability where you rent

Condominium Owners covers personal property, liability, additions & alterations, and loss assessments for condominium/townhome unit owners

Recreational Vehicle covers golf carts, snowmobiles, motorcycles, four-wheelers, boats, motors, trailers, etc.

LIFE/HEALTH/DISABILITY COVERAGE

* If we do not write any of the following coverage for you, please indicate if you are interested in a quotation *
	Quote Desired

Life provides funds for those left behind. Would you like a review of the beneficiaries, ownership and cash values of your life insurance policies?

Disability provides replacement income as a result of extended sickness or injury

Health pays medical and related expenses

Long-term Care — Provides home healthcare and/or nursing home benefits

HOW ARE WE DOING?

IS THERE ANY WAY WE CAN IMPROVE OUR SERVICE TO YOU? IS THERE ANYTHING NOT MENTIONED ALREADY THAT HAS CHANGED AND YOU THINK IT MIGHT AFFECT YOUR PERSONAL COVERAGE?

YOUR INFORMATION

	Name:
	Date:
	Phone Number:
	*E-mail Address:

To bind coverage you need to speak directly with a licensed agent of Vaaler Insurance.

*Required Fields

Personal Insurance Program Questionnaire

Personal Insurance
Program Questionnaire