It is important to periodically review your personal insurance program to determine if we are still providing the best solutions for your needs. To assist us with this review, we ask that you take a few minutes to answer the following questions:

First Name:
Last Name:
Daytime Phone Number:
Email Address:
Please re-enter your Email Address:
Preferred method of contact:

			Personal Automobile – If we currently provide your automobile insurance, please answer the following:
	YesNo		1. Are you interested in increasing your automobile liability limits? (Higher liability limits may be available at more competitive rates. Please let us know if you would like a quote for higher limits.)
	YesNo		2. Are all of your cars and licensed drivers in your household listed on your automobile policy?
	YesNo		3. Do you want to include rental reimbursement and towing & labor coverage in the event that your car is damaged in an accident?
			Homeowners/Personal Property – If we currently provide your homeowners and/or personal property insurance, please answer the following:
	YesNo		1. Would you like to review the adequacy of the current insured value of your home and other structures?
	YesNo		2. Would you like to review the adequacy of your personal property or contents coverage?
	YesNo		3. Have you made (or are you planning to make) any additions or renovations to your home?
	YesNo		4. If you own a condominium or co-op, do you need coverage for any upgrades, alterations or permanently installed fixtures? These items may not be covered under the association’s master policy.
	YesNo		5. Are you interested in finding out about mold, earthquake or flood insurance protection? (Please circle your interest.)
	YesNo		6. Do you need us to provide coverage for a secondary residence or any other properties that you own?
	YesNo		7. Many homeowners policies do not include back up coverage of sewers, drains and sump pumps. Would you be interested in getting a quote for this coverage?
	YesNo		8. In the past year, many homeowners insurance companies have instituted hurricane and windstorm deductibles that are separate and much higher than what is typical. Would you like to review your policy to determine if there has been a deductible change for these exposures?
	YesNo		9. Do you operate a business out of your home? (Most homeowners policies provide little or no coverage.)
	YesNo		10. There are special limitations on jewelry, silver, furs, collections, fine arts, etc., within your homeowners policy. Coverage for these items can be increased or specifically scheduled. Would you like to review your coverage needs for these items?
			Other Coverages
	YesNo		1. Are you interested in a Personal Excess Liability Policy (Umbrella), or higher liability limits than you presently carry?
	YesNo		2. If you have any automobiles, recreational items or properties insured elsewhere and have a Personal Excess Liability Policy (Umbrella) with us, do you have liability limits with us of at least $300,000?
	YesNo		3. Do you serve as a director, officer or member of a board for a public, private and/or non-profit organization?
	YesNo		4. Do you need coverage for any recreational items such as watercraft (including jet skis), motorcycles, snowmobiles, aircraft, etc.? (Please circle your interest.)
	YesNo		5. Do you have domestic employees working in your home(s)? Your homeowners policy may provide limited Worker's Compensation coverage for domestic employees. You may need additional Worker's Compensation and/or Employment Practices Liability Coverage.
	YesNo		6. Would you like us to contact you regarding: HomeownersPersonal Excess Liability (Umbrella) Life InsuranceFinancial Planning AutomobileBusiness Insurance Long Term Health Care Insurance
	YesNo		7. Good student grades, driver training, centralized alarms, home ownership, and multi-policy discounts are just a few examples of the discounts our carriers offer you. Please let us know if you have experienced any changes that would affect your eligibility for discounts?
	YesNo		8. Are there any other areas not covered by these questions that you wish to discuss regarding your insurance program?
We appreciate you taking the time to complete this form. Please sign and return it by mail, fax or email. Once we receive the form we will update our records and if necessary contact you. Thank you for allowing Bollinger an opportunity to be of service. Sincerely, Personal Lines Agent