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Thursday, February 23, 2012
Homeowners Survey
Confirmation of Client Information
Name
Address 1
Address 2
City
State
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
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Washington
West Virginia
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ZIP
Phone
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Please select "Yes" or "No" to the following statements:
Home Improvements
I have made additions/improvements in excess of $25,000 to my home and/or other structures on my property. If construction has not yet begun please contact us immediately to ensure you are fully covered during construction.
Yes
No
New Purchases
I have purchased additional jewelry, furs, fine arts and/or silverware, which are not specifically scheduled on my policy. Your homeowner policy has coverage limitations! It’s also important to re-appraise your valuables every five years to assure proper values.
Yes
No
Security System
I have installed security devices, such as a local/central burglar and/or fire alarms. (Credits to your premium may be available)
Yes
No
Recreational Vehicles
I own a recreational vehicle (ATV, Golf Carts, Mini Bike. Snowmobile, Motorcycle, Motor home, moped, motor scooter, dune buggy or all-terrain vehicle) and need to purchase liability coverage. Please call us for more details.
Yes
No
Boats
I own a watercraft and/or jet-ski
Yes
No
Home Office
I am now conducting a business in my home or in an additional other structure on my property.
Yes
No
Second Home
I own or have purchased an additional residential location(s), which I occupy or rent.
Yes
No
Other Structures
I have an additional other structure(s) on my property, which I rent to others.
Yes
No
Umbrella
I would like to add/increase personal excess liability umbrella coverage. (We recommend a minimum of $5,000,000 of coverage.)
Yes
No
Domestic Employees
I employ a full or part time domestic employee for more than twenty (20) hours per week. (Worker’s Compensation is required by law, for individuals employed more than twenty (20) hours per week whether or not they have working papers.)
Yes
No
Employers Practices Liability Coverage
If you have domestic employees, please advise if you would like to purchase
Employers Practices Liability Coverage
, which protects you from Sexual Harassment, Wrongful Termination or Discrimination Laws.
Yes
No
Mold Remediation
I would like to obtain a quotation for additional MOLD remediation coverage. Current policy has limited coverage. Please refer to your policy for the specific limits.
Yes
No
Earthquake
I would like to obtain a quotation for Earthquake coverage for my home.
THIS IS NOT A COVERED PERIL ON THE HOMEOWNER POLICY.
Yes
No
Estate & Financial Planning
I am interested in learning more about the latest Estate Planning and Wealth Management techniques and would like to be contacted.
Yes
No
Flood
I would like to obtain a quotation for a Flood Policy.
FLOOD COVERAGE IS EXCLUDED FROM YOUR HOMEOWNER POLICY.
Yes
No
Board Members
Are you presently a board member of a corporation, charitable organization or not-for-profit organization and desire
Directors and Officers Coverage
?
Yes
No
Long Term Care
I would like to obtain a quotation for Long Term Care.
Yes
No
New Drivers
Are there any newly licensed drivers in your household?
Yes
No
Additional Comments
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The ELS Group | 900 Merchants Concourse | Westbury, NY 11590-9005 | Phone: (516) 228-3535 | Fax: (516) 228-3537
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