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Auto Renewal Checklist


AUTO POLICY RENEWAL CHECK LIST

The purpose of this form is to help us prevent any situations where a claim is denied do to an unreported change regarding your vehicles.  Please take 5 minutes and complete this online form to help us provide you with the
Best Service with the Best Protection at the Lowest Possibe Price!  Thank you for your assistance.



Policy number (if you have it handy)
Optional
First Name
Required
Last Name
Required
Street
Required
City
Required
State / Province
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Do we insure all the vehicles you own? If not, please tell us who does.
Required
Would you be interested in increasing your Liability Limits (Property and Bodily)?
Optional
Are any vehicles NOT registered or titled in you and/or your spouse's name? If so, which vehicle and whose name?
Required
Would you like to save money on your insurance by increasing your deductibles?
Required
Would you be interested in obtaining information on $1,000,000 umbella liability protection for as little as $3/week?
Required
Do you own a pickup or van that contains customized equipment, camper or shell? If yes, please explain.
Required
Do you own a mini-bike, moped, motorized scooter or motorcycle?
Required
Do you own any ATVs, boats, snowmobiles, jetskis, motorhomes or travel trailer?
Required
Do you have any students away at college? If so, who?
Required
Have you or your spouse changed jobs in the last 2 years? If so, how far are you (or your spouse) driving one way and in which car?
Required
If you don't already have "Rental Car Coverage" would like coverage for about $25 in premium per year?
Required
Is there anyone that lives in your home that is not listed on your auto policy? If so please provide their name, birthday and relation to you.
Required
Do you have a teenager that is going to get their permit in the next year? If so, what is their name and birthday?
Required
If your car is towed, would you like coverage that would reimburse you for that?
Required
Are any of your vehicles used for business? If so, how?
Required
Additional Comments
Optional
Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
   
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