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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

Required

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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