Package Renewal
Please answer the below questions to reflect any changes within the last 12 months.
Full Name
*
Please select your agent's name
Who is your agent?
Paula Brevig
Marsha Eggers
Lisa Schuster
Hunter Sutherland
Jeff Chihak
Rich Dalton
Matt Fleming
Kyle Graf
Josh Johnson
Patricia Meeks
Wes Thomas
Jeff Monaco
Tanner Williams
I don't know
Hidden
Agent's Email
Auto Renewal
Did you move?
No
Yes
List your new address
Apartment, suite, etc.
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP
Have you recently paid off your vehicle and need to remove the lienholder?
No
Yes
Which vehicle?
Is a driver not listed on your policy currently using your vehicle?
No
Yes
Please list drivers who should be added to your policy.
First name
Last name
Driver's license
Date of birth
MM slash DD slash YYYY
How many miles is your commute (one way)?
How many miles will you drive annually?
Under 10,000
10,000 - 20,000
20,000 - 30,000
30,000 - 40,000
40,000 - 50,000
50,000 - 60,000
60,000 - 70,000
70,000 - 80,000
80,000 - 90,000
90,000 - 100,000
100,000 +
Have you stopped using your vehicle to get to work?
No
Yes
Did you start using your vehicle for work?
No
Yes
What type of work?
Is your vehicle used for Rideshare (Uber, Amazon Flex, Lyft, GrubHub)?
No
Yes
Would you like us to apply a discount for downloading an app that tracks drivers safety? Many carriers give a 10 to 15% discount for this. (Not applicable to all carriers)
No
Yes
Home Renewal
Did your mortgage lender change in the last 12 months?
No
Yes
Please list your current mortgage lender
Is your home deeded in the name of a trust?
No
Yes
What is the name of the trust and who are the trustees?
Did you recently renovate or make any significant structural additions to your home?
No
Yes
Did you have your roof replaced?
No
Yes
Date of replacement
MM slash DD slash YYYY
Did you update any of the following in the last 12 months?
Wiring
Heating
Plumbing
None
Wiring Date of replacement
MM slash DD slash YYYY
Heating Date of replacement
MM slash DD slash YYYY
Plumbing Date of replacement
MM slash DD slash YYYY
Did you have a burglar, fire or safety alarm system installed?
(Monitored by companies such as ADT, Brinks, etc.)
No
Yes
Did you have a gas alarm installed?
(Such as carbon monoxide alarm or automatic gas main shut-off)
No
Yes
Did you get a new dog?
No
Yes
Please list breed
Did you add solar panels to your home?
No
Yes
Do you own or lease the panels?
No
Yes
How many panels do you own?
Please list the purchase price of the solar system
Did you have a pool, spa or sauna installed?
None
Pool
Spa
Sauna
Does the pool have a diving board or slide?
No
Yes
Did you install a trampoline?
No
Yes
Is it netted?
No
Yes
Do you conduct business or work from home?
No
Yes
What type of business?
Do you have a wood burning fireplace?
No
Yes
Do you have collectibles: antiques, fine art, stamps, coins, etc.?
No
Yes
What do you collect?
Do you own jewelry pieces valued over $2,500?
No
Yes
Average dollar value per collectible?
Do you currently rent or do you intend to rent your home to a third party, including home exchanges and short-term rentals via AirBnB, VRBO or other companies?
No
Yes
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