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To make sure you're adequately protected, we recommend a yearly review of all of your insurance policies. This questionnaire helps make that review quick and efficient. Please take a moment to answer the questions and email, fax (262-697-1961) or mail this page back to us. Keep in mind you should always advise your insurance agent of any life, automobile, and or home changes, including additions, improvements, and moves.

Automobile/Vehicle


  1. Would you consider increasing your deductibles to lower your premium?

  2. Do we currently insure all of the vehicles in your house­hold? If not, how many do you insure elsewhere?

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

  4. Would you like to include your car stereo (if mounted under the dash), DVDs, CDs, CB or two-way radio on your auto policy for an additional premium?

  5. If you own a pickup or a van, does it contain any cus­ tomized equipment?

  6. Do you own a pickup camper or a camper shell?

  7. Do you own minibikes, mopeds or motorcycles? If so, how many?

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

  9. Do you want rental reimbursement or towing and labor coverage in the event that your car is damaged in an acci­dent?

  10. Do you own any boats, motorbikes, motor homes or other recreational vehicles such as snowmobiles or golf carts?

  11. Would you like a quote for higher limits of liability insurance or personal injury protection?

  12. Do you have other electronic devices you wish to cover (e.g., GPS)?


Homeowner/Renter/Condos


  1. Do you own any antiques, fine arts or collections, such as unique dishes and figurines?

  2. Do you own any jewelry or furs? If so, what is the total appraised value of such items?

  3. Do you own valuable camera equipment, silverware or guns?

  4. Do you frequently carry or keep in your home more than $100 in cash?

  5. Do you have a coin or stamp collection?

  6. Would you prefer to cover your personal belongings for their full replacement value (i.e., no deduction for depreciation)?

  7. Would you be interested in adding earthquake or flood insurance to your homeowners protection? (If yes, which one(s))

  8. Do you currently have a burglar, fire or smoke alarm; fire extinguishers; or dead bolts on all doors in your home? (If yes, which one(s))

  9. Would you like an estimate of your home's replacement cost at today's prices?

  10. Would you like home replacement guarantee protection?

  11. Do you own a second home or any other real property, such as a cabin, farm property or any income-producing property?

  12. Are you engaged in any form of farming or ranching?

  13. Do you conduct any business (including child care) or give private lessons in your home?

  14. Would you be interested in an umbrella or excess liability policy that extends your auto and homeowners liability coverage to $1 million or more?

  15. Do you keep your business computer at home?


Other Personal Insurance


  1. Do you have disability income insurance in case you become sick or disabled?

  2. Are you aware that accidental death and disability insur­ance for you and your family is available at low cost?

  3. Are you concerned about estate taxes?

  4. Do you have a mortgage redemption insurance policy (which pays off your house in the event of your death)?

  5. Are all members of your family protected by life insurance?

  6. Would you like a review of the beneficiaries, ownership and cash values (if any) of your life insurance policies?

  7. Are you interested in discussing life insurance within the next year?

  8. Do you have a retirement or pension plan?

  9. Are you self-employed? If so, have you heard about SEP or Keogh retirement plans, and would you like to know more?

  10. Is your health insurance up to date?

  11. If you are a self-employed professional, would you like a quote for business property, professional liability or malpractice insurance?

  12. Have you been contributing to an IRA (standard or Roth)?

  13. Are you interested in other financial services?





SOURCE - Mines Press - COPYRIGHT ©2018. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is understood that the publishers are not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert advice is required, the services of a competent professional should be sought. 2/18.

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