Family Risk Assessment Personal Lines Questionnaire Family Risk AssessmentName First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Auto & HomeWould you consider increasing your deductibles to lower your premium? Yes No Do we presently insure ALL of the vehicles of your household? Yes No Why not?Are ALL of the licensed drivers in your household listed on your Auto Policy? Yes No Would you like to include any aftermarket installed electronic equipment? Yes No Do any of your vehicles contain any customization? Yes No Do you have any vehicles that would require an AGREED VALUE? Yes No Do you own a pickup camper unit or camper shell? Yes No Do you own minibikes, mopeds, ATV's or motorcycles? Yes No Do you have vehicles furnished for your regular use that you do not own? Yes No Do you want Roadside Assistance coverage on your policy? Yes No Do you want Rental Reimbursement coverage on your policy? Yes No Homeowners & RentersDo you own any of the following? Antiques Fine Arts Silverware Unique Collections Jewelry Furs Valuable Camera Equipment Do you frequently carry, or keep in your home, more than $200 cash? Yes No Do you have a coin or stamp collection? Yes No Do you own any guns? Yes No Would you prefer to cover your personal belongings for their full replacement value? Yes No Have you prepared a Home Inventory of ALL of your belongings? Yes No Would you like assistance in doing so? Yes No Do you have a Burglar Alarm? Yes No Is it a Central Station Burglar Alarm? Yes No Do you have a Smoke or Heat Alarm? Yes No Is it a Central Station Smoke or Heat Alarm? Yes No When was the last time the Replacement Cost of your home was evaluated? Within the past year 2-5 years ago More than 5-years ago Do you understand the three different valuations that are on your home? Yes No Market 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 No Do you own any other real property such as vacant land or farm property? Yes No Are you presently engaged in any form of farming or ranching? Yes No Do you conduct any business or give private lessons in your home? Yes No Do you own any of the following? A Boat? A Motorcycle? An ATV or UTV? A Snowmobile? A Golf Cart? Another type of Recreational Vehicle Would you be interested in Earthquake coverage? Yes No Do you know whether or not you're in a Flood Plain? Would you be interested in Flood Insurance? Yes No Would you be interested in an Umbrella policy that extends your Auto & Homeowners Liability coverage up to $1M or more? Yes No Life, Health, and FinancialDo you have Disability Income Insurance in case you become sick or disabled? Yes No Are all members of you family protected by Life Insurance? Yes No Do you have Mortgage Redemption Insurance, which pays off your house in the event of your death? Yes No Do you have an up-to-date Will? Yes No Does everyone know where your important documents, such as Will, financial documents and insurance policies are located? Yes No Has anyone ever helped you determine exactly how much Life Insurance you need? Yes No Do you have any idea how much money you need when you retire? Yes No Are you concerned about estate taxes? Yes No Do you have a retirement or pension plan? Yes No What are YOUR greatest concerns right now in regards to your overall Financial Plan?