Ramsburg Family Insurance Review

First Name *

Last Name *

Social Security Number

E-Mail Address *

Home Phone Number *

Work Number

Cell Phone Number

Occupation

Highest Level of Education

ZIP / Postal Code *

Number of Household Residents

Spouse Name

Spouse Email

Work Number

Cell Phone Number

Occupation

Preferred method of contact

Home Phone
Work Phone
Cell Phone
Email Phone

Homeowners Coverage

Have you or are you planning on investing $15,000 or more in renovating your home? (Interior or exterior)

Yes
No

If yes, projected or finished date of renovation.

/

Please provide approximate years of updates or repairs to the following:

Plumbing System *

Type of Plumbing

Type of Fuel

Electrical System *

Roofing *

Roof *

Exterior

Do you have any supplemental heat such as a wood, coal, pellet or gas stove?

Yes
No

Does your home have a security system?

Yes
No

Is your basement Finshed ?

Yes
No

If Yes, Approximate value of the finished area

Do you have a sump pump? *

Yes
No

If yes, Do you have a water intrusion alarm or battery back up?

Yes
No

Do you have any structures on the property that are not attached to your home—such as a garage, pool house, cabana, gazebo, pergola, sports court, and outdoor living area (built in barbeque or rock/masonry seating areas)? *

Yes
No

Do you own any boats, jet skis, recreational vehicles, snowmobiles, ATV’s or golf carts? *

Yes
No

Do you own any items valued over $1,000? (i.e. Furs, Fine Arts, Guns , Coins, Other Collectible Items) *

Yes
No

Do you have professional tools or equipment on your premises for business use? *

Yes
No

Do you have a pool on your property? *

Yes
No

If yes, is it an In-ground or Above-ground pool?

In-ground
Above-ground

Is the pool fenced or have a locking or removable ladder?

Yes
No

Do you have any pets? *

Yes
No

If Yes , What type of pet(s):

Do you have a ..... ?

Trampoline *

Yes
No

Skate Ramp

Yes
No

Tree House

Yes
No

Other Recreational Structure

Yes
No

Are any of your children attending school away from home? *

Yes
No

If yes, number of students attending school away from home:

On or off campus?

On
Off

Do they have high value items with them at school?

Yes
No

Have you refinanced or paid off your home? *

Yes
No

Are any members of your household living in an assisted living facility?

Yes
No

Do you have a vacation home or 2nd residence?

Yes
No

Automobile Coverage

Have you acquired any new vehicles not listed on your policy?

Yes
No

Do you have a Company Car?

Yes
No

Do you car pool?

Yes
No

Do you own any Trailers?

Yes
No

Do you have any children attending school away from home that have a vehicle with them?

Yes
No

If yes, please list child, college attending and which vehicle

Do you own any vehicles that are insured with another carrier that is not insured with our agency?

Yes
No

Important Concerns

Have you made any major lifestyle changes that might alter your insurance needs? Marrying, Divorcing or Retiring?

Yes
No

Have you changed the ownership structure on your property? (Started a Trust or an LLC?)

Yes
No

If you have Life Insurance, do you have enough coverage to pay off your home mortgage?

Yes
No

Do you have Long Term Disability Insurance to Protect you family if you were disabled?

Yes
No

Are you interested in protecting your retirement assets with Long Term Care Insurance?

Yes
No

Ask yourself, “How will my family manage financially if I die?” We have affordable insurance plans and life insurance rates have dropped significantly within the past few years.

Do you have the protection that your family will need to maintain their lifestyle or pay for college? When was the last time you had a financial check-up?

Additional Notes, Information & Instruction

Date Submitted *

/