Renewal Questionnaire This questionnaire if for clients that have Personal Insurance with us, such as home and auto insurance. "*" indicates required fields Today's Date* MM slash DD slash YYYY Client Name*Please Enter the name listed first on your insurance policies First Last Are you married?* Yes No What's your spouse's full name?* What's your spouse's email? What's your spouse's phone number? Please confirm your address?*Simply to make sure we're working on the right profile. Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mobile Phone:*Text Messages*Please let us know if you approve contact via text messageYes - ApprovedNo - Do Not TextEmail Address*Please Provide Us With Your Best and Preferred Email Address Preferred Method of Contact*TextPhoneEmail What personal insurance lines do you currently have with My Insurance Group?* Personal Auto Homeowners Landlord Flood Stand Alone (Texas Windstorm) Personal Umbrella Watercraft Recreational Vehicle / Travel Trailer Motorcylce / ATV / UTV Life Insurance Personal AutoDrivers*Please List All Household Members Over The Age of 15 and provide Date of Birth. We will cross reference this list with the list we have on file to ensure accuracy. How Many Vehicles Do You Currently Own?*For the purpose of this review, we would like to know about your private passenger automobiles. 12345Vehicle 1* Year Make and Model Annual Miles Driven Principal Operator Vehicle 2* Year Make and Model Annual Miles Driven Principal Operator Vehicle 3* Year Make and Model Annual Miles Driven Principal Operator Vehicle 4* Year Make and Model Annual Miles Driven Principal Operator Vehicle 5* Year Make and Model Annual Miles Driven Principal Operator Additional Vehicles*Please Provide the Details of All Other Vehicles Not Previously ListedAre any vehicles on the policy used for transportation for hire, such as Uber or Lyft?* Yes No Please list the vehicle(s) used for Rideshare*Our clients save 18% annually when completing carrier telematics generally within 90 days. Are you interested? By the way, you can opt out so don't be nervous.* Yes No Insureds who pay in full can save up to 10%. Are you interested?* Yes No Do you have any additional questions, concerns, or feedback regarding your auto insurance policy?* Yes No Please Describe your Questions, Concerns, or Provide Any Feedback.* HomeownersWho is your mortgage company? We need to make sure the right company receives the renewal invoice.*Have there been any recent changes in your mortgage company information? Does anyone, except a mortgagee, have financial interest in your home? Do you have a second mortgage or home equity line of credit?Any home updates or improvements?Have there been any additions or updates to your home? Ex pool, solar panels, remodeling, additions, updates to the water, heating, plumbing, electrical or roof Yes No If Yes, Please provide a value and description for all improvements*Home SharingDo you rent your home as part of a home-sharing or short term renting program like AirBnb, VRBO or other? Yes No Do you have any pets? Yes No Please describe the number, type, and breed of pets (if dogs)*Do you have any additional questions, concerns, or feedback regarding your home insurance policy?* Yes No Please Describe your Questions, Concerns, or Provide Any Feedback.* Landlord / Rental PropertyWho is your mortgage company? We need to make sure the right company receives the renewal invoice.*Have there been any recent changes in your mortgage company information? Does anyone, except a mortgagee, have financial interest in your home? Do you have a second mortgage or home equity line of credit?Any home updates or improvements?Have there been any additions or updates to your home? Ex pool, solar panels, remodeling, additions, updates to the water, heating, plumbing, electrical or roof Yes No If Yes, Please provide a value and description for all improvements*Home SharingDo you rent your home as part of a home-sharing or short term renting program like AirBnb, VRBO or other? Yes No Umbrella PolicyAny significant changes in your assets or net worth that may require an adjustment in your personal umbrella policy coverage limits? Yes No If yes, please explain:Have you added or changed any recreational vehicles, boats, or other property to include houses that might warrant additional liability coverage under your personal umbrella policy? Yes No If yes, please list:Any changes in your household, such as new drivers, family members moving in or out, or changes in employment status, that could affect your personal umbrella policy coverage? Yes No If yes, please explain: Watercraft PolicyHave you made any modifications or purchased new equipment for your watercraft in the past year that may require an update to your policy? Yes No If yes, please explain to include value:Has your watercraft usage changed, such as frequency of use, different bodies of water, or participating in new activities (e.g., water sports, fishing, or chartering), which may impact your policy? Yes No If yes, please explain:Have there been any changes to the storage or mooring location of your watercraft, or have you transported your boat to new locations that might affect your watercraft policy? Yes No If yes, please explain: RV / Travel TrailerHave you made any upgrades or purchased new accessories for your RV or travel trailer in the past year that may require updates to your insurance policy? Yes No If yes, please explain to include value:Has there been a change in frequency of use such as taking longer trips, participating in new activities, or riding in different locations, that could affect your insurance policy coverage? Yes No If yes, please explain:Are you renting your RV or Travel Travel to others? Yes No Are you using a program such as RVshare or Outdoorsy? Yes No Motorcycle / ATV / UTVHave you made any upgrades or purchased new accessories for your motorcycle or ATV/UTV in the past year that may require updates to your insurance policy? Yes No Please explain: Life InsuranceHave there been any life events in the past year such as marriage, divorce, birth or adoption of a child, or a change in dependents that could affect your life insurance coverage needs? Yes No Please explain:Have you experienced any changes in your financial situation such as an increase in income, assets, or debt that might warrant a re-evaluation of your policy coverage amount or type? Yes No Please Explain:Have you made any updates to your estate plan or designated beneficiaries for your life insurance policy in the past year? Yes No Please explain:Do you need assistance reviewing or updating this information to ensure it is accurate and up-to-date? Yes No Finally...Do you have ANY insurance polices outside of PIE?*For us to do a complete job in making sure you are protected, we need to be aware of any additional policies or assets you may have purchased to ensure there are no gaps in coverage. Yes No Policies outside of agency:* Auto Rental Property(ies) Personal Umbrella RV or Travel Trailer Homeowners Life / Mortgage Protection Flood Watercraft Motorcycle or ATV Farm or Ranch Business/Commercial None at this time Personal AutoWho's your current auto carrier:* What kind of vehicles do you have?Year, make, and modelWho are the household members of driving age?Name and date of birth How much are you paying monthly from your auto insurance?* Landlord / Rental PropertyHow many rental properties do you own?* Addresses of all rental properties:Who's your current rental property carrier:* Do you use this property for short term rentals such as AirBNB or VRBO* Yes No Do you require the tenants to have tenant insurance?* Yes No Are the property(ies) professionally managed?* Yes No HomeownersWho's your current home insurance carrier: What's your current home insurance premium: RV / Travel TrailerWho's your current RV/Travel Trailer carrier:* What kind of RV/Travel Trailer do you have?Year, make, and modelDo you use a rent your RV / Travel Trailer to others?* Yes No Do you use a rental program such as RVShare or Outdoorsy?* Yes No How much are you paying monthly?* WatercraftWho's your current watercraft carrier:* What kind of watercraft do you have?Year, make, and modelHow much are you paying monthly?* Motorcylce / ATV / UTVWho's your current Motorcycle / ATV / UTV carrier:* What kind of Motorcylce / ATV / UTV do you have?Year, make, and modelHow much are you paying monthly?* Farm or RanchWho's your current Farm or Ranch carrier? What activities are you doing on your farm or ranch?Farming, Hunting, etc.. Business / CommercialWhat kind of business do you own? We love feedback!!Do you have any feedback for us? Is there an area we can improve your experience?CAPTCHA
