Free Family Risk Questionnaire from PA Insurance Rates.com

FREE FAMILY RISK QUESTIONNAIRE
We are concerned about Protecting Your Assets properly. Taking a few minutes to fill out and
submit this brief checklist will determine if you have any gaps in your insurance coverage.
By working together we can provide you with the Peace of Mind of knowing your Insurance Program is up to date. Thanks for using this free service!

Personal Information

Legal Name:

Address:

City: State: Zip:

Home Phone: Business Phone:

Cell Phone:

Email Address:

AUTOMOBILE/VEHICLE

(Please complete this section even if you do not have your auto insurance through our agency)

Yes/No

/ 1. Would you consider higher deductibles to lower premiums? What amount would you be comfortable retaining? Coll. $ Comp. $

/ 2. Do we presently insure all of the vehicles in your household? If not, how many do we insure? of vehicles.

/ 3. Are all of the licensed drivers in your household listed on your Auto policy?

/ 4. If you own a pickup or a van, does it contain any customized equipment?

/ 5. Are any of your vehicles used in any type of business?

/ 6. Does anyone in your household own or operate any type of recreational vehicle, such as a motorcycle, ATV, snowmobile, etc?

/ 7. Do you have vehicles furnished for your regular use that you do not own, such as a company car? If so, how many?

/ 8. Do you want rental reimbursement coverage in the event that your car is damaged in an accident?

/ 9. Do you want towing coverage to pay for towing or temporary repairs at the site of a breakdown?

HOMEOWNERS/RENTERS

(Please complete this section even if you do not have your homeowners/renters insurance through our agency)

Yes/No

/ 1. Do you own any valuable items that need special coverage…such as jewelry, collectibles, furs, firearms, silverware, paintings, etc?

/ 2. Do you have a business in your home from which you earn an income?

/ 3. Would you be interested in Backup of Water & Sewer coverage?

/ 4. Would you be interested in Sinkhole, Earthquake, or Flood coverage?

/ 5. Have you installed a fire and/or burglar alarm system in your home?

/ 6. Do you have children residing away at school?

/ 7. Do you own any boats that need to be insured?

/ 8. Are you concerned about Identity Fraud?

/ 9. Would you prefer to protect your personal belongings against damage by the broadest range of perils available?

/ 10. If you live in a condominium, can assessments be levied against you? If so, what is the maximum amount?

/ 11. Do you own a second home or any other real property, such as a mountain cabin, shore home or farm property

/ 12. Do rent any portion of your home, or own any property that you rent to others?

/ 13. Are you presently engaged in any form of farming for an income?

/ 14. Do you give private lessons in your home?

/ 15. Do you have a pool or hot tub?

/ 16. Do you have a trampoline or skate board ramp on your property?

/ 17. Do you own any type of animal? If a dog, what breed?

PERSONAL LIABILITY:

Yes/No

/ 1. Are you concerned about protecting your assets from large liability claims or lawsuits?

ADDITIONAL COVERAGES/SERVICES:

(Please complete this entire section)

Yes/No

/ 1. Are you concerned about continuing your income in the event you become sick or disabled?

/ 2. Are you interested in knowing more about Long Term Care insurance?

/ 3. Are you concerned about your spouse's ability to pay your mortgage in the event of your premature death?

/ 4. Are you interested in a Life Insurance Review?

/ 5. Do you have a current will?

/ 6. Are you involved in any business ownership or professional practice? Please describe briefly:

Name:
Type of Business:

Address:
Position:

/ 7. Would you like us to review the adequacy of your business insurance program?

Additional Comments

Please click the Submit button only once to submit your questionnaire.
We will review it and contact you to complete your analysis.

Please call me at this number:
The best time to call me is:

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Personal Information
Legal Name:
Address:
City:	State: Zip:
Home Phone:	Business Phone:
Cell Phone:
Email Address:

AUTOMOBILE/VEHICLE
(Please complete this section even if you do not have your auto insurance through our agency)
Yes/No
/	1. Would you consider higher deductibles to lower premiums? What amount would you be comfortable retaining? Coll. $ Comp. $
/	2. Do we presently insure all of the vehicles in your household? If not, how many do we insure? of vehicles.
/	3. Are all of the licensed drivers in your household listed on your Auto policy?
/	4. If you own a pickup or a van, does it contain any customized equipment?
/	5. Are any of your vehicles used in any type of business?
/	6. Does anyone in your household own or operate any type of recreational vehicle, such as a motorcycle, ATV, snowmobile, etc?
/	7. Do you have vehicles furnished for your regular use that you do not own, such as a company car? If so, how many?
/	8. Do you want rental reimbursement coverage in the event that your car is damaged in an accident?
/	9. Do you want towing coverage to pay for towing or temporary repairs at the site of a breakdown?

HOMEOWNERS/RENTERS
(Please complete this section even if you do not have your homeowners/renters insurance through our agency)
Yes/No
/	1. Do you own any valuable items that need special coverage…such as jewelry, collectibles, furs, firearms, silverware, paintings, etc?
/	2. Do you have a business in your home from which you earn an income?
/	3. Would you be interested in Backup of Water & Sewer coverage?
/	4. Would you be interested in Sinkhole, Earthquake, or Flood coverage?
/	5. Have you installed a fire and/or burglar alarm system in your home?
/	6. Do you have children residing away at school?
/	7. Do you own any boats that need to be insured?
/	8. Are you concerned about Identity Fraud?
/	9. Would you prefer to protect your personal belongings against damage by the broadest range of perils available?
/	10. If you live in a condominium, can assessments be levied against you? If so, what is the maximum amount?
/	11. Do you own a second home or any other real property, such as a mountain cabin, shore home or farm property
/	12. Do rent any portion of your home, or own any property that you rent to others?
/	13. Are you presently engaged in any form of farming for an income?
/	14. Do you give private lessons in your home?
/	15. Do you have a pool or hot tub?
/	16. Do you have a trampoline or skate board ramp on your property?
/	17. Do you own any type of animal? If a dog, what breed?

PERSONAL LIABILITY:
Yes/No
/	1. Are you concerned about protecting your assets from large liability claims or lawsuits?

ADDITIONAL COVERAGES/SERVICES:
(Please complete this entire section)
Yes/No
/	1. Are you concerned about continuing your income in the event you become sick or disabled?
/	2. Are you interested in knowing more about Long Term Care insurance?
/	3. Are you concerned about your spouse's ability to pay your mortgage in the event of your premature death?
/	4. Are you interested in a Life Insurance Review?
/	5. Do you have a current will?
/	6. Are you involved in any business ownership or professional practice? Please describe briefly:
	Name: Type of Business:
	Address: Position:
/	7. Would you like us to review the adequacy of your business insurance program?