Step 1 of 13

Name(Required)

First Last

Email(Required)

Occupation(Required)

Higher Education:(Required)

Are you driving for a rideshare or delivery company?

Yes

If yes what company?

Have you started using your vehicle for business?

Yes

(Roofing, real estate, advertisement, etc.)

What Business?

Please check all situations that apply to you.

Address Change

Birth of a child

Career Change

Driver Added

Driver Removed

Home renovations/improvments

Marital Status

Purchased ATV/Motorcycle/Slingshot

Purchased Boat

Purchased Home/Rental Property/Second Home

Started A Business

Vehicle Bought

Vehicle Sold

No Changes

Date You Moved

MM slash DD slash YYYY

Updated Address

Street Address Address Line 2 City State ZIP Code

Name(Required)

Birthday

Congrats on the new career! What is your new job title?

Add Driver To Policy(Required)

First Last

Birthday

Relationship to You

DL #

Remove Driver From Policy(Required)

First Last

What is your current marital status?

Married

Divorced

Widowed

Spouse Name(Required)

What new toy(s) did you purchase?

ATV

Boat

Golf Cart

Motorcycle

Slingshot

List make, model and estimated purchase price for each new toy.

Year

Make

Model

Click the + to add more rows.

What type of property did you purchase?

Primary Home

Rental Home/Investment Property

Second Home/Vacation Home

Date Purchased

MM slash DD slash YYYY

New Property Address

Street Address Address Line 2 City State ZIP Code

Is the Property currently insured? With who?

What is the name of your new business?

What is the industry of your new business?

Is your business currently insured?

Yes

Date Purchased

MM slash DD slash YYYY

Year/Make/Model of purchased vehicle(s)

Year

Make

Model

Click the + to add rows for additional vehicles.

Date Sold

MM slash DD slash YYYY

Year/Make/Model of sold vehicle(s)

Year

Make

Model

Click the + to add rows for additional vehicles.

Please list the renovations and an approximate cost of each.

You can use the + button on the right side to add additional rows.

Are there any additional changes that we should know about prior to your insurance renewal?

Personal Insurance Review

Today's Date

MM slash DD slash YYYY

Auto Insurance Protection

Let’s say you were driving to work tomorrow, had an accident, you were at fault, and there was 300,000.00 in damages. Would you want your policy to pay all damages?

Let’s say you had a few glass claims (could be broken window or a wind shield that needs replaced), would you prefer to pay for that out-of-pocket or would you prefer for your insurance premiums to go up to cover that cost?

If you had damage to your car, would you rather have a lower deductible for less out-of-pocket cost, or would prefer to lower your premiums by choosing a higher deductible?

How many licensed drivers are in your household?

Home Insurance Protection

Do you have an insurance policy that covers your outstanding mortgage:

Do you have any jewelry you would want replaced if it were lost on vacation?

Have you made any improvements or additions to your home over the past couple of years? ex: plumbing, electrical, roof, HVAC, etc.

If you HAVE made any improvements or additions to your home over the past couple of years, please describe below:

If you had a sewer backup and your carpet or flooring was ruined, would you want it replaced by your policy?

Have you added a burglar alarm or other security device since your last policy renewal?

If you DO have a burglar alarm or other security device, please describe below:

Let’s say you were involved in an accident in your car, or someone hurt themselves on your property, and you were sued for $1,000,000. Where would you want the money to come from?

General Questions

Do you have any income producing hobbies?

Details if YES, you do have any income producing hobbies:

Do you have any collections, such as guns, art, or jewelry?

Details if YES, you do have any collections:

Do you have any vacation homes or rental properties?

Details if YES, you have any vacation homes or rental properties:

Do you have an inventory of all your household possessions in photo/video form, or an itemized list?

If YES, how do you have the inventory saved and/or would you like us to help you make sure this list has everything listed that is needed:

Have you made any major purchases during the past year?

Details if YES, you have made any major purchases during the past year:

Have there been any major family dynamic changes during the past year (examples: marriage, birth, deaths, adoptions, etc.)?

Details if YES, you have had major family dynamic changes during the past year:

Recreational Vehicle Protection

Do you have any vehicles such as boats, motorcycles, ATV’s that you would want coverage on?

Details if YES, you do have any vehicles such as boats, motorcycles, ATV’s that you would want coverage on:

Life Insurance

If you were to pass away, would you want there to be a check for your family to help pay the bills?

Do you currently have a life insurance policy outside of your employer?

Important Little Details

Would you be interested in purchasing additional life insurance on top of what you currently have in place?

What policies do you currently have in place that are NOT with First Choice Insurance?

All of my policies are with First Choice Insurance

Auto

Homeowners

Umbrella

Recreational Vehicles

Life

Business

Would you like us to quote your insurance on the policies that you do NOT currently have with First Choice Insurance?

Service

Has anyone in our office provided exceptional service at any time?

Are you satisfied with your insurance program with our agency?

Can you think of any friends, relatives, or neighbors that we can help with their insurance needs?

Would you like information on our referral programs?

If you are not satisfied with your insurance program with our agency, please tell us why:

If we have any questions arise before your review meeting, what is the best phone number and time to reach you?

Preferred method of contact

Are there any additional changes that we should know about prior to your insurance renewal?

Our renewal specialist, Kristin Smith, would love to schedule an appointment with you to go over your insurance policy renewal. Please make a call at 702-805-8393 to schedule an appointment with her. Moreover, please note whether you would like your appointment to be in-person or via phone call.

Phone

This field is for validation purposes and should be left unchanged.

Personal Renewal Form

Personal Insurance Review

Auto Insurance Protection

Home Insurance Protection

General Questions

Recreational Vehicle Protection

Life Insurance

Important Little Details

Service