Annual Home Insurance Review

Home Insurance Renewal Review

Please complete this brief questionnaire to help us make sure you are adequately covered by your home insurance plan.

"*" indicates required fields

Step 1 of 13

Name*

First Last

Cell Phone*

May we text you?

Yes

We occasionally send out information about events going on at our office, info on your current policies and an occasional product offering.

Email*

Enter Email Confirm Email

If you had damage to your home, would you rather have a lower deductible for less out-of-pocket or would you prefer to lower your premiums by choosing a higher deductible?*

Lower deductible, higher premium

Higher deductible, lower premium

Have you made any improvements or additions to your home over the past couple of years?*

Yes

Additions such as room additions, and improvements such as new roof, furnace, plumbing or electric or any others that can effect the value of your home.

What improvements or additions have you made?*

Have you updated your heating system?*

Yes

What type of heating system did you install and when was it installed?

Have you replaced your roof?*

Yes

What type of roof did you install and what date?

Have you rewired your house or updated your electric panel?*

Yes

What was updated with your electrical system and when?

Have you updated or replaced any plumbing?*

Yes

What has been updated or replaced with your plumbing system? What type of plumbing and when?

If you were to have a total loss on your home, would you want to have replacement cost on the home itself?

Yes

Replacement cost on the home provides coverage above your selected dwelling limit. Some companies offer different percentages that they will pay above your insured amount such as 125% or 150%. Some companies even offer guaranteed replacement cost, where there is no limit.

Do you have any jewelry you would want replaced if it were lost on vacation?*

Yes

If yes, please list details and value of the jewelry.

If you had a sewer backup and your carpet was ruined, would you want it replaced?*

Yes

Do you want damages from a flood or earthquake to be covered by your policy?*

Yes

If your home or an outbuilding collapses into a sinkhole, would you want insurance to pay for the damages?*

Yes

If your heating system breaks down, would you want insurance to cover the repairs or replacement?*

Yes

Select all options you are interested in having covered:

Earthquake

Flood

Both Earthquake and Flood

If someone steals your identity and you have expenses to repair and/or recover your identity, would you want it to be covered under your home insurance policy?*

Yes

If there was a cyber attack or cyber extortion on your personal computer, tablet or smart phone, would you want coverage for the expenses?*

Yes

Cyber Attack • Data Recovery Costs - Cost of a professional firm hired to replace electronic data that has been lost or corrupted. • System Restoration Costs - Cost of a professional firm to restore the computing or connected home device to its level of functionality before the cyber attack. This includes the replacement or reinstallation of software programs, removal of malicious code and the configuration of the device or system. Cyber Extortion • Professional assistance from a subject matter expert for advice and consultation on how to best respond to a threat. • Cyber Extortion Response Costs - Payment as directed to the extortion threat, when payment is approved in advance and incurred as the direct result of a cyber extortion event. Fraud • The direct financial loss to an insured as the result of a fraud event including but not limited to identity theft, unauthorized use of a card, card number, or account number in an insured’s name, or forgery of a check. Data Breach • Forensic IT Review - Cost for a professional information technologist to review the nature and extent of the breach event, the number and identities of the affected individuals. • Legal Review - Cost for a professional legal counsel to review and develop a response for the personal data compromise. • Notification to Affected Individuals - Necessary and reasonable costs to provide notification of the personal data compromise to affected individuals. • Services to Affected Individuals - Cost to provide informational materials and telephone helpline to affected individuals. Credit Report and Monitoring and Identity Restoration Case Management services provided

Let's say you were involved in an accident in your car or someone hurt themselves on your property, and you were sued for $1,000,000. Where would you want the money to come from?*

My insurance policy

It's not something I'm concerned about

I don't know

I would like more information

Have you added a burglar and/or fire alarm system?*

Yes

Are you interested in a paid in full discount?*

Yes

Do you have any collections, such as guns, art, collector cards, coin collections or any other type of collection?*

Yes

Please list any collections or collectables along with their values:

Do you have any vacation homes or rental properties?*

Yes

Do you have any income producing hobbies?*

Yes

Do you have an inventory of all your household possessions?*

Yes

Do you do any work at home for your employer?*

Yes

Have you made any major purchases during the past year?*

Yes

If yes, please provide details of any major purchases.*

Do you have any recreational vehicles such as boats, motorcycles, dirt bikes, ATV, Side by Sides, jet skis or snowmobiles that you would want coverage on if damaged or stolen?*

Yes

What insurance polices are not placed with DSB Insurance Agency?*

Auto

Home

Business

Umbrella

Life

Annuity

Recreational Vehicles

Disability

Long Term Care

Would you like us to provide a quote for any of the polices not placed with DSB Insurance Agency?*

Yes

Are you looking to sell and/or purchase another home within the next 6 months?

Yes

If you are looking to purchase or sell your home in the next 6 months would you be interested in being referred to one of our associates/referral partners?

Yes

Are you looking to refinance your home or take out a home equity loan within the next 6 months?

Yes

If you are looking to refinance or take out a home equity loan would you be interested in being referred to one of our associates/referral partners?

Yes

Has anyone in our office provided exceptional service at any time? If yes, please tell us about it.

Are you satisfied with your insurance program with our agency? If so, can you think of any friends or neighbors we can help? May we send you information on our referral rewards program?

If you are not satisfied with your insurance program with our agency, can you please tell us why or what we can do to help solve the problem?

Would you like to schedule an appointment for a homeowners review?*

Yes

Home Insurance Renewal Review

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