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?YesNoDo we presently insure ALL of the vehicles of your household?YesNoWhy not?Are ALL of the licensed drivers in your household listed on your Auto Policy?YesNoWould you like to include any aftermarket installed electronic equipment?YesNoDo any of your vehicles contain any customization?YesNoDo you have any vehicles that would require an AGREED VALUE?YesNoDo you own a pickup camper unit or camper shell?YesNoDo you own minibikes, mopeds, ATV's or motorcycles?YesNoDo you have vehicles furnished for your regular use that you do not own?YesNoDo you want Roadside Assistance coverage on your policy?YesNoDo you want Rental Reimbursement coverage on your policy?YesNoHomeowners & 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?YesNoDo you have a coin or stamp collection?YesNoDo you own any guns?YesNoWould you prefer to cover your personal belongings for their full replacement value?YesNoHave you prepared a Home Inventory of ALL of your belongings?YesNoWould you like assistance in doing so?YesNoDo you have a Burglar Alarm?YesNoIs it a Central Station Burglar Alarm?YesNoDo you have a Smoke or Heat Alarm?YesNoIs it a Central Station Smoke or Heat Alarm?YesNoWhen was the last time the Replacement Cost of your home was evaluated?Within the past year2-5 years agoMore than 5-years agoDo you understand the three different valuations that are on your home?YesNoMarket 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?YesNoDo you own any other real property such as vacant land or farm property?YesNoAre you presently engaged in any form of farming or ranching?YesNoDo you conduct any business or give private lessons in your home?YesNoDo 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?YesNoDo you know whether or not you're in a Flood Plain? Would you be interested in Flood Insurance?YesNoWould you be interested in an Umbrella policy that extends your Auto & Homeowners Liability coverage up to $1M or more?YesNoLife, Health, and FinancialDo you have Disability Income Insurance in case you become sick or disabled?YesNoAre all members of you family protected by Life Insurance?YesNoDo you have Mortgage Redemption Insurance, which pays off your house in the event of your death?YesNoDo you have an up-to-date Will?YesNoDoes everyone know where your important documents, such as Will, financial documents and insurance policies are located?YesNoHas anyone ever helped you determine exactly how much Life Insurance you need?YesNoDo you have any idea how much money you need when you retire?YesNoAre you concerned about estate taxes?YesNoDo you have a retirement or pension plan?YesNoWhat are YOUR greatest concerns right now in regards to your overall Financial Plan? This iframe contains the logic required to handle Ajax powered Gravity Forms.