| Coverages |
| Desired Comprehensive
Personal Liability? |
|
|
| Desired deductible
amount? |
|
|
| Medical Payments to Others if hurt
on your property? |
|
|
| |
| Questions |
| When do you
need insurance by? |
|
(mm/dd/yy) |
| How long have you lived at your
present address? |
|
|
| If you have coverage now,
who is the Insurance Company? |
|
|
| Current Insurance Premium? |
|
|
| How long have you been with
this company? |
|
|
| Is your policy being Canceled
or Non-Renewed? |
|
Yes
No |
| If you have had any reported
claims in the last Five years, please briefly explain? |
|
|
| To receive a larger
discount would you consider also insuring your cars? |
|
Yes
No |
| Do you have
any Questions or Suggestions? |
|
|
Refer
a Friend 
