All Saints Insurance - Personal Insurance Review

You deserve an attentive insurance agency that cares that you have the right insurance protection. Please take 5 minutes to share, confirm and update your information. This form helps us identify potential discounts and other coverage issues that should be discussed.

First Name:

Last Name:

Phone Number

Area CodePhone Number

Email

example@example.com

Add Spouse and/or authorized person on your account?

YesNo or N/A

First Name2:

Last Name2:

Best Phone Number to reach you 2

Area CodePhone Number

Email 2

example@example.com

Mailing Address the same as your physical address?

YesNo

Physical Address

Street Address

Street Address Line 2

City

Street Address Line 2

City

Street Address Line 2

State

City

Street Address Line 2

Zip Code

Mailing Address (if different)

Address

Street Address Line 2

CityState

Zip Code

Current Policies with our Agency: (please check all that apply)

Changes in your life/work

	Yes	No	N/A
Change in marital status, recent or upcoming?
Any new kids in the family?
Changed jobs recently?
Anyone work out of a home office?
Anyone in household self-employed full- or part-time?
If self-employed, is anyone working for you on a full- or part-time basis?
Hire anyone to work in your home such as a nanny, a housekeeper, a caregiver, etc.?
Anyone create or post content for a website or a blog for work/pleasure?
Change of address, recent or upcoming?
None of the Above apply (choose N/A)

Review specific needs: Home/Dwelling/Condo

To help avoid gaps in coverage, please provide information even if you have policies through a different source.

Home & Valuables

	Yes	No
Made any home improvements that you haven’t informed us of?
Consider increasing your deductible to lower your premium?
Store business property at your residence or in your vehicle?
Have a second home or investment property home
Rent all or a portion of any properties that you own
Have any valuable jewelry, guns, collectibles, etc. that we have not discussed?
Home is in a legal trust? .
Recently paid off your mortgage?
Mortgage changed/sold to another company?

Home & Valuables: Please enter answers to all "Yes" questions here:

Review specific needs: Vehicles

To help avoid gaps in coverage, please provide information even if you have policies through a different source.

Coverage considerations:

Vehicles :

	Yes	No	N/A
Any new drivers in your household?
Garaging address changed and now different from home address? (garaging means location where a vehicle is primarily parked overnight)
Any vehicle(s) have customized equipment permanently installed
Recently paid off a loan on your vehicle
Any vehicle used for any business purposes?
Use a company car that you don’t own?
Anyone not listed as a driver on your policy use your vehicle(s) regularly?
None of the Above apply (choose N/A)

Vehicles Section: Please enter answers to all "Yes" questions here:

	Yes	No
You or your spouse/partner have an auto policy elsewhere?
Consider increasing your deductible to lower your premium?
Cars(s) have anti-theft device(s) of any type?
Member of a motor club, i.e. AAA, GM Motor Club, Onstar, etc.?
Low annual mileage on any of your vehicle(s)? Vehicle & mileage?
Use public transportation to commute to work on an ongoing basis?
A student on your policy lives away at school at a distance of 100+ miles?
A student on your policy has a grade average of “B” or 3.0 or higher?
A driver has completed an approved advanced driver training program?
Are you currently on an automatic payment plan?
Do your home and auto liability limits cover your assets (home equity, retirement,savings, etc.)

	Yes	No
Towing and labor for a disabled vehicle
Rental/substitute transportation in the event of an accident
Rental/substitute transportation in the event of an accident
Auto loan/lease gap coverage*
New vehicle replacement value coverage*
Accident forgiveness policy feature*
Disappearing deductible for no accidents feature** (Only available through certain insurance carriers. Qualifying restrictions and limitations apply.)

	Yes	No
Have a boat?
Have a motorcycle?
Have an ATV?
Have a golf cart?
Other recreational vehicle(s)?

	Contact me for info/quote	I have a policy elsewhere	No Interest/ Decline/ Currently have with All Saints	Expiration Dates
Personal umbrella liability policy – extra protection over and above auto/home policies
Auto insurance
Motorcycle insurance
Homeowner, Condominium or Renter policy
Special coverage for high valued jewelry, fine arts, antiques, etc
Water backup and sump discharge or overflow coverage
Earthquake insurance
Flood insurance
Business insurance
Life insurance - other than an employer provided policy
Group Benefits
Other - Please contact me to discuss

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
Service Quality
Responsiveness
Friendliness

Tel: 985-201-8700

Personal Insurance Review

Current Policies with our Agency: (please check all that apply)

Changes in your life/work

Review specific needs: Home/Dwelling/Condo

Review specific needs: Vehicles

Vehicle Discounts and potential savings:

Review specific needs: Toys

Additional Coverage Needs

Agency Experience