Personal Insurance Renewal Questionnaire

HOMEOWNER / DWELLING FIRE

* 1. Have you had wind mitigation inspection completed on your home?

Yes

No

* 2. Have you made any improvements to your home that may have increased the replacement cost?
Compare your home's replacement cost to your current property coverage, as it is ultimately the policy holder's responsibility to ensure they have adequate coverages.

Yes

No

* 3. Is the name on the policy the same as that shown on your deed?

Yes

No

* 4. Are any properties deeded as an LLC or Trust?

Yes

No

* 5. Basic policy coverage is limited for certain items, such as jewelry, fine arts, antiques, furs, silver, firearms, computers, cameras, collections and business property. Would you be interested in specifically insuring your items?

Yes

No

* 6. Do you operate a business from your home? If so, what types of business operations are performed in your home and do clients or suppliers come to your home?

No

Yes

* 7. Do you have any pets or animals? If so, please advise the type and breed.

No

Yes

* 8. Would you be interested in a quote for higher liability limits?

Yes

No

* 9. Your property policy does not provide flood insurance or storm surge. If you do not have a flood policy, would you be interested in a quote?

Yes

No

If not with Bouchard, please advise name of insurance company & renewal date

AUTOMOBILE / MOTORCYCLE / RECREATIONAL VEHICLE / AIRCRAFT

* 10. Is the name on the policy the same as that shown on the title or lease?

Yes

No

* 11. Are all licensed drivers who are residents of your household (including children away at school) listed on your policy?

Yes

No

* 12. If not with Bouchard, are there any youthful drivers in the household?

Yes

No

* 13. Do you use your vehicle for business purposes at any time?

Yes

No

* 14. Do you regularly use a vehicle you do not own?

Yes

No

* 15. Do you own motorcycles and/or recreational vehicles: boats, jet skis, motor homes, golf carts or any aircraft? If "Yes" and NOT written with Bouchard, please describe vehicle(s) and advise the name of the insurance company and expiration date:

No

Yes

* 16. Do you wish to review your uninsured/underinsured motorists coverage, or discuss coverage options?

Yes

No

UMBRELLA

* 17. If you do not have personal umbrella liability insurance, would you be interested in this policy, which would give you increased liability limits above your homeowner, automobile, motorcycle or recreational vehicle(s) policy limits?

Yes

No

IMPORTANT INFORMATION: If you have an Umbrella policy with Bouchard Insurance, we need to know about all residential property, personal vehicles, motorcycles, recreation vehicles and drivers that we do not insure in order to include them under your umbrella policy.

If you have an Umbrella policy, but not through Bouchard Insurance, please advise the name of the insurance company and expiration date:

GENERAL

* 19. Are there any other situations or exposures that we should be aware of? Explain below:

Yes

No

* First Name

* Last Name

* Street Address

* City

* State

* Zip Code

* Phone Number

* Email Address

* Indicates Response Required