Premier One Insurance Auto- Home- Business- Life- Health

Just as your health needs an annual checkup, so does your insurance coverage. Please take time to complete this checklist concerning your auto and homeowner insurance needs. When you’re finished, stop by or call our agency with any questions you may have about your coverage, or about any changes you want to make.

E-mail Address: *

Name *

Address

City

State

Zip

1. Do you have collectibles such as antiques, fine art, stamps, coins, or baseball cards? *
Yes No
Describe

2. Do you own valuable jewelry or furs? *
Yes No
Describe

3. Do you own costly sporting equipment or firearms? *
Yes No
Describe

4. Do you have valuable cameras or other photography equipment? *
Yes No
Describe

5. Do you have any alarms installed in your home? *
Yes No
If So, What Type

6. Do you keep more than $100 cash in your home? *
Yes No
7. Are your personal belongings insured for their full replacement value? *
Yes No
8. Do you have children away at college? *
Yes No
If so, are their possessions insured? *
Yes No
9. Do you own tools, equipment, or instruments used in your trade or profession? *
Yes No
Describe

10. Do you operate an office or studio in your home? *
Yes No
11. Do clients come into your home to make purchases? *
Yes No
12. Do you baby-sit in your home? *
Yes No
13. Do you have a dog, cat, or other pet that may pose a risk to others? *
Yes No
14. Have you recently remodeled or redecorated your home? *
Yes No
Do you have plans to do so? *
Yes No
15. If your home suffered an entire loss, would your insurance cover your home’s full replacement value? *
Yes No
16. Are you interested in flood insurance for your home and personal property? *
Yes No
17. Are you interested in earthquake coverage? *
Yes No
18. Do you use a wood-burning stove? *
Yes No
19. Do you have a swimming pool? *
Yes No
20. Do you own rental or investment property? *
Yes No
21. Do you own a vacation home (i.e., condo, cabin, or trailer)? *
Yes No
22. If you rent, do you carry renters insurance? *
Yes No
23. If you own a condo, do you have condo insurance? *
Yes No
24. Do you plan to purchase a new vehicle this year? *
Yes No
If so would you like us to provide you with an insurance estimate on the vehicle(s) *
Yes No
25. Does our agency insure all your vehicles? *
Yes No
26. Does your automobile policy specify by name all of the *
Yes No
27. Do you routinely use vehicles you do not own? *
Yes No
28. Do you have CD’s, cassette tapes, or non-factory installed equipment (car phones,stereos, CD players, etc.) in your car? *
Yes No
If so, would you like a quote on insuring these possessions? *
Yes No
29. Do you own a vehicle with custom furnishings or equipment (i.e., a conversion van)? *
Yes No
30. If your vehicle were damaged in an accident, would your current automobile insurance reimburse you for a rental vehicle while your is being repaired? *
Yes No
31. Do you own any of the following recreational vehicles?
NA Boat Motorhome Motorcycle Camper Golf Cart Moped All-Terrain Vehicle Snowmobile Jet Ski
32. Do you carry at least a one-million-dollar umbrella liability policy? *
Yes No
33. Do you own a business? *
Yes No
If so, do we currently insure it? *
Yes No
34. Do you plan to start a business? *
Yes No
35. If you know anyone else who could benefit, please provide Name

Phone

Email


Verification Code:
Enter Verification Code: *

General Questions

Policy Changes

Claims

Online Payments

Document Request

Policy Check Up

Feedback