Home & Auto Renewal Questionnaire Today's Date* MM slash DD slash YYYY Client Name*Please Enter the name listed first on your insurance policies First Last Mobile Phone:*Text Messages*Please let us know if you approve contact via text messageYes - ApprovedNo - Do Not TextEmail Address*Please Provide Us With Your Best and Preferred Email Address Preferred Method of Contact*TextPhoneEmail AcknowledgementsAcceptance of Coverage*Your input is ESSENTIAL in our attempt to eliminate gaps in your insurance coverage. Please accept that you have reviewed your current and existing insurance policy(ies) and accept the coverages you currently have. This checklist is used prior to the renewal of your insurance policy(ies) for the purpose of verifying your coverage is up to date. This checklist does not cover every situation, but is a starting point to prompt you to consider major items and questions. Yes I accept Acknowledgement of Truth and Good Faith*I hereby certify that all statements included in the checklist are true and correct to the best of my knowledge. I understand that any false statements may lead to claims being denied, premiums to be adjusted, and/or policies ultimately canceled. Yes, I certify the following answers to be true What Personal Insurance Products Do You Currently Have With Ameriguard Insurance Agency?* Personal Auto Renters Homeowners Personal Umbrella Boat Recreational Vehicle/Motorcycle Life Insurance General Life Changes that may impact insurance (Check all that may apply to you or members of your household) Had a baby Got Married or Engaged Got separated or divorced Purchased a secondary home or investment property Someone moved in or out of your household (including children or parents) Auto Policy ReviewDrivers*Please List All Household Members Over The Age of 15 and provide Date of Birth. We will cross reference this list with the list we have on file to ensure accuracy. How Many Vehicles Do You Currently Own?*For the purpose of this review, we would like to know about your private passenger automobiles. 123456More Than 6Vehicle 1* Year Make and Model Annual Miles Driven Principal Operator Vehicle 2* Year Make and Model Annual Miles Driven Principal Operator Vehicle 3* Year Make and Model Annual Miles Driven Principal Operator Vehicle 4* Year Make and Model Annual Miles Driven Principal Operator Vehicle 5* Year Make and Model Annual Miles Driven Principal Operator Vehicle 6* Year Make and Model Annual Miles Driven Principal Operator Additional Vehicles*Please Provide the Details of All Other Vehicles Not Previously ListedCustom Equipment*Do any of your vehicles have custom equipment? Ex. stereo systems, after market parts or grill guards, custom rims, performance accessories, etc. NoYesIf Yes, Please Describe:*Please specify that equipment, it's value, and which vehicle it has been added to.Do any of the drivers listed on the policy work from home?*You may be eligible for a discount if you work from home. No Yes If Yes, Please Describe*Please list which driver works from home and how many days per week they work from home. Do you have a company car furnished to you that you park at your home and use on a regular basis?* No Yes Delivery*Do you or any drivers listed on the policy use any vehicles listed on the policy for delivery for hire, such as Doordash, Uber Eats, Shipt, etc... No Yes Please Describe Any Deliveries*Ridesharing*Are any vehicles on the policy used for transportation for hire, such as Uber or Lyft? No Yes Please list the vehicle(s) used for Rideshare*Auto Insurance Discounts (check those that may apply to you or members of your household)*** Not all discounts are available with all carriers. Each carrier has different discounts Drivers Safety Course Completion (Age 55+) Good Student Discount (3.0 GPA or higher) Child away at college (75+ miles away or more) without a car Do you have any additional questions, concerns, or feedback regarding your auto insurance policy?* Yes No Please Describe your Questions, Concerns, or Provide Any Feedback.* Renters PolicyPlease review the personal property limit on your renters policy. Do you feel this limit is adequate to replace all the "stuff" in your apartment?*YesNoWhat should the limit be?* HomeownersPurchased Property?*Have you bought or sold a house, vacation property, farm, vacant land since your last insurance review?NoYesIf Yes, Please DescribeMortgage Company*Have there been any recent changes in your mortgage company information? Does anyone, except a mortgagee, have financial interest in your home? Do you have a second mortgage or home equity line of credit?If yes, Please describe home based business operations*Home - Outbuildings*Is the "Other Structures (Coverage B)" adequate to cover all outbuildings, shops, sheds, detached garages, carports, fences, awnings, etc?YesNoIf No, Please provide a limit and description for all additional structures*Home - Updates and Improvements*Have there been any additions or updates to your home? Ex. remodeling, improvements, additions, updates to the water, heating, plumbing, electrical or roof? *Is the amount of insurance on your home less than it would take to rebuild it?NoYesIf Yes, Please provide a value and description for all improvements*Home Sharing*Do you rent your home as part of a home-sharing/renting program like AirBnb, VRBO or other? NoYes Home & Apartment QuestionsDoes Your Home, Rental Home, or Apartment Have A Basement?*NoYesDo you have any of the following:* Sump Pump Battery Backup Sump Pump Water Intrusion Alarm Home Business*Do you have any hobbies or conduct any business from you home that grosses more than $2,000 per year? *There are limitations and exclusions for businesses at home, in your garage or renting out space to others for business purposes.NoYesDo you have any valuables, collectibles, valuable jewelry, fire arms, silverware*Do you have any antiques, fines arts, silverware, collectibles, valuable jewelry or furs? Or sporting equipment, guns, musical instruments? *Many policies have limitations to the coverages available for these items, unless they are scheduled.NoYesIf Yes, Please give a description of the item(s) and a value*Home and Apartment Safety / Smart Features* Monitored Burglar Alarm Monitored Fire Alarm Fire Alarm / Smoke Detectors Fire Extinguisher Smart Water Leak Detector Smart Thermostat Security Cameras Do you have any pets?*We realize that people add pets to their household families and these can have implications with regards to your insurance. YesNoPlease describe the number, type, and breed of pets (if dogs)* Finally...Do you have ANY other insurance outside of Ameriguard Insurance Agency?*For us to do a complete job in making sure you are protected, we need to be aware of any additional policies or assets you may have purchased to ensure there are no gaps in coverage. Yes No Please Describe*Do you have any other insurance needs we can address?* Personal Umbrella Auto Homeowners/Rental Flood Boat or Personal Watercraft Motorcycle or ATV Farm or Agriculture Business/Commercial Life Insurance None at this time Who else do you know we may be able to help?One of the greatest compliments anyone can give our agency is to refer us a new customer. Name First Last PhoneEmail Feedback*Do you have any feedback for us? Is there an area we can improve your experience? Is there a team member you'd like to give kudos to for their effort?Please check if you would like to have a phone conversation with a member of our team to discuss anything at all.If you check this box, you will be sent a link to schedule a time to have a phone conversation with a member of our team. Yes, I would like to receive a call