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)

First Name *

Last Name *

Street *

City *

State / Province *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Do we insure all the vehicles you own? If not, please tell us who does. *

Would you be interested in increasing your Liability Limits (Property and Bodily)?

Are any vehicles NOT registered or titled in you and/or your spouse's name? If so, which vehicle and whose name? *

Would you like to save money on your insurance by increasing your deductibles? *

Would you be interested in obtaining information on $1,000,000 umbella liability protection for as little as $3/week? *

Do you own a pickup or van that contains customized equipment, camper or shell? If yes, please explain. *

Do you own a mini-bike, moped, motorized scooter or motorcycle? *

Do you own any ATVs, boats, snowmobiles, jetskis, motorhomes or travel trailer? *

Do you have any students away at college? If so, who? *

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? *

If you don't already have "Rental Car Coverage" would like coverage for about $25 in premium per year? *

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. *

Do you have a teenager that is going to get their permit in the next year? If so, what is their name and birthday? *

If your car is towed, would you like coverage that would reimburse you for that? *

Are any of your vehicles used for business? If so, how? *

Additional Comments

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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