Home Policy Protection Checklist
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Home Policy Protection Checklist
Client Name
Insured Property Address
City
State
Zip
Policy Number
Renewal Date of Policy
Email
Home Phone
Work Phone
Cell Phone
Please indicate Yes, No, or Insured meaning you already have the coverage.
Question 1.
Have you remodeled your home, added any additions, built any outbuilding or garages, or made any improvements to finish your basement?
Please Select
Yes
No
Insured
Question 2.
Would it cost more to rebuild your home, than the amount you have it insured for?
Please Select
Yes
No
Insured
Question 3.
Have you updated the wiring, heating, roof or plumbing in your home?
Please Select
Yes
No
Insured
Details
Question 4.
Would you like to SAVE Money by increasing your deductible???
Please Select
Yes
No
Insured
Question 5.
Have you acquired any valuable guns, jewelry or collectable items?
Please Select
Yes
No
Insured
If yes, explain
Question 6.
Have you added a new security or fire alarm system to your home?(If so please provide us with the installation certificate to receive a discount.)
Please Select
Yes
No
Insured
Question 7.
Are you running any business out of your home or do you give private lessons on your premises?
Please Select
Yes
No
Insured
Question 8.
Are you babysitting two or more children in your home on a regular basis?
Please Select
Yes
No
Insured
Question 9.
Do you own any ATVs, boats, snowmobiles, or other recreational vehicles?
Please Select
Yes
No
Insured
Question 10.
Do you have a trampoline?
Please Select
Yes
No
Insured
Question 11.
Do you have any pets? If so please list the type of pet, breed and how many?
Please Select
Yes
No
Insured
Type, Breed, How many?
Question 12.
Do you have any rental or investment properties?
Please Select
Yes
NO
Insured
Question 13.
Do you own a second home such as a weekend or summer property? If so what is the address?
Please Select
Yes
No
Insured
Address
Question 14.
Have you refinanced or changed your mortgage company this year, if so what is the mortgage company’s name, address, loan number, and phone number?
Please Select
Yes
No
Insured
Company Name, Address, Loan number, Phone number:
Question 15.
Would you be interested in obtaining information on a $1,000,000 Umbrella Liability Insurance policy that would protect you in the event of a catastrophic accident for as little as $150 per year?
Please Select
Yes
No
Insured
Question 16.
Would you like to have Flood coverage – annual price begins at $320?
Please Select
Yes
No
Insured
Question 17.
Would you like to have Earthquake coverage– annual price begins at $120?
Please Select
Yes
No
Insured
Question 18.
Would you like to have backup of Sewer & Drain Backup Coverage?
Please Select
Yes
No
Insured
Question 19.
Would you like more information about purchasing Identity Theft Protection?
Please Select
Yes
No
Insured
Question 20.
Would you like to have your premium spread over 12 months and drafted from your checking account in order to have NO SERVICE FEES?
Please Select
Yes
No
Insured
Question 21.
Would you like a FREE No Obligation Review of your families Life Insurance Needs?
Please Select
Yes
No
Insured
The name of the person that completed this form and the date. By typing your name and date below you are electronically signing this document acknowledging that all the information is true.
Name
Date
Do you have any additional comments?
Message
Thank you for completing this form. It is a very important part of your insurance protection. Your form will be reviewed to ensure we have all the information you indicated. If you have requested additional information we will contact you. If you would like to speak with a member of the O’Connor Insurance Team please check below.
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