Family Risk AssessmentPersonal Lines Questionnaire Family Risk AssessmentName First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Auto & HomeWould you consider increasing your deductibles to lower your premium? Yes NoDo we presently insure ALL of the vehicles of your household? Yes NoWhy not?Are ALL of the licensed drivers in your household listed on your Auto Policy? Yes NoWould you like to include any aftermarket installed electronic equipment? Yes NoDo any of your vehicles contain any customization? Yes NoDo you have any vehicles that would require an AGREED VALUE? Yes NoDo you own a pickup camper unit or camper shell? Yes NoDo you own minibikes, mopeds, ATV's or motorcycles? Yes NoDo you have vehicles furnished for your regular use that you do not own? Yes NoDo you want Roadside Assistance coverage on your policy? Yes NoDo you want Rental Reimbursement coverage on your policy? Yes NoHomeowners & RentersDo you own any of the following? Antiques Fine Arts Silverware Unique Collections Jewelry Furs Valuable Camera EquipmentDo you frequently carry, or keep in your home, more than $200 cash? Yes NoDo you have a coin or stamp collection? Yes NoDo you own any guns? Yes NoWould you prefer to cover your personal belongings for their full replacement value? Yes NoHave you prepared a Home Inventory of ALL of your belongings? Yes NoWould you like assistance in doing so? Yes NoDo you have a Burglar Alarm? Yes NoIs it a Central Station Burglar Alarm? Yes NoDo you have a Smoke or Heat Alarm? Yes NoIs it a Central Station Smoke or Heat Alarm? Yes NoWhen was the last time the Replacement Cost of your home was evaluated? Within the past year 2-5 years ago More than 5-years agoDo you understand the three different valuations that are on your home? Yes NoMarket Value--What it would sell for. Tax Value--What the county values it for in regards to your property taxes. Replacement Cost--What it would cost to rebuild it at today's prices.Do you own a second home? Yes NoDo you own any other real property such as vacant land or farm property? Yes NoAre you presently engaged in any form of farming or ranching? Yes NoDo you conduct any business or give private lessons in your home? Yes NoDo you own any of the following? A Boat? A Motorcycle? An ATV or UTV? A Snowmobile? A Golf Cart? Another type of Recreational VehicleWould you be interested in Earthquake coverage? Yes NoDo you know whether or not you're in a Flood Plain? Would you be interested in Flood Insurance? Yes NoWould you be interested in an Umbrella policy that extends your Auto & Homeowners Liability coverage up to $1M or more? Yes NoLife, Health, and FinancialDo you have Disability Income Insurance in case you become sick or disabled? Yes NoAre all members of you family protected by Life Insurance? Yes NoDo you have Mortgage Redemption Insurance, which pays off your house in the event of your death? Yes NoDo you have an up-to-date Will? Yes NoDoes everyone know where your important documents, such as Will, financial documents and insurance policies are located? Yes NoHas anyone ever helped you determine exactly how much Life Insurance you need? Yes NoDo you have any idea how much money you need when you retire? Yes NoAre you concerned about estate taxes? Yes NoDo you have a retirement or pension plan? Yes NoWhat are YOUR greatest concerns right now in regards to your overall Financial Plan?