Personal Information - A User's Checklist

Transcription

1 Date: Name: Qualifying Questions Were you referred to us? Yes No Best Number to Reach You At: If no, how did you hear about us? Referral Reward Program Referred By: Initial Thank You, Coupon Sent to Client (Form letter/memo/referral Letter) Centurytel Yellow Pages Baraboo Radio Yellow Book TV Ad Saw our sign/drive by. Other Portage Billboard Portage Radio Midwest Directory-Portage Association Plus (West Bend Mutual) Verizon Yellow Pages-Portage Pioneer Directories-Yellow Pages Previous Customer Existing Customer Commercial Client For us to Quote a monoline piece of business, one of the following questions must be answered yes: * Existing Client in Our Agency Yes / No * Customer was a Referral Yes / No * Nancy/Dennis Ok d Yes / No What coverages are we quoting for you? Have you had at least 1 year of auto coverage with no lapse in coverage? Are you a homeowner? If Auto, Have you or any household member had any Major Violations in the last five years? Driving while suspended or revoked (OWS, OAR, OWD) Violation of Occupational License (VOO) Operating While Intoxicated (OWI, IC, OII, NHI, OCS, OWH) Failure to stop after accident (FSA, FSU) Racing, Speed Excess, Reckless Driving (R, SE, RD) Felony involving a motor vehicle (VUF) Attempting to Elude an Officer (AEO) Intoxicant in Vehicle or Underage Alcohol Operation (IVO, IVP, IIV, UAO) If Auto, Do you need an SR-22? What is your expiration date on your policy? Date/Time you would like the quote by? What agency do you have your insurance with now and how long have you been with them? Why did you decide to buy insurance with them? Have you had any issues with them? If yes, how were they handled and or what should they do to make you happier? Would you have a Walk-In office preference of : Baraboo, Holmen or Portage? (Circle One) May I ask what your renewal premium is now? No/Yes-> $ Term: What Type of Pay Plan? Other Notes: **Property or Vehicles Owned by anyone other than person applying for insurance - If Yes, additional Name(s) may need to be added to policy.

2 Privacy Policy Notice as of July 1, 2001 At Don-Rick, Inc. maintaining customers trust and confidence is a high priority. That is why we want to protect your privacy when we collect and use information about you, and why we take measures to safeguard that information. We want you to know your privacy concerns are important to us; in accordance with law we are supplying you with this privacy statement. Chapter INS 25 of the Wisconsin Administrative Code generally prohibits any licensees of the Office of the Commissioner of Insurance, directly or through it s affiliates, from sharing nonpublic personal information about you with a non-affiliated third party unless the institution provides you with a notice of it s privacy policies and practices, such as the type of information it collects about you and the categories of persons or entities to whom it may be disclosed. In compliance with the Wisconsin Administrative Code, we are providing you with this document, which notifies you of the privacy policies and practices of Don-Rick, Inc.. Our Privacy Policies and Practices Information we collect. We collect nonpublic personal information about you from the following sources: Information we receive from you on applications or other forms. Information about your transactions with us, our affiliates or others. Information we receive from a consumer reporting agency. Information we may disclose to third parties: 12 We do not disclose any nonpublic personal information about our customers or former customers to anyone, except as permitted by law (e.g., to insurance carriers for underwriting purposes). Our practices regarding information confidentiality and security: 13 We restrict access to nonpublic personal information about you to those employees who need to know that information in order to provide products or services to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information. Reservation of the right to disclose information in unforeseen circumstances: 14 In connection with any potential sale or transfer of its interests, Don-Rick, Inc. reserves the right to sell or transfer your information (including but not limited to your address, name, age, sex, zip code, state and country of residency and other information that you provide through other communications) to a third party entity that (1) concentrates its business in a similar practice or service; (2) agrees to be the Don-Rick, Inc. successor in interests with regard to the maintenance and protection of the information collected; and agrees to the obligations of this privacy statement. Amendment to Privacy Notice and Privacy Policy: We reserve the right to amend, modify or change at any time and for any reason, our privacy policies and this privacy notice. In any such events, we will provide an amended Privacy Notice to you. I acknowledge the privacy statement above. I understand any proposal is subject to company underwriting guidelines based on the information I have provided and may be subject to change based on this information and that insurance scoring may be used to determine my rates. I understand that any Values Used or Property Cost Estimators produced in the case of Homeowners/Condominium Owners Policies are estimates based on the information provided or available to our agency. A professional appraisal of your property(s) is recommended and should be provided to us for the most accurate valuation. I understand that higher limits and optional deductibles are available and it is my responsibility to contact my agent to make these changes as well as reading my policy for coverage conditions and exclusions. I authorize any employee of Don-Rick, Inc. to contact (call) me regarding any and all matters regarding any products and or services they offer at any time and run the necessary C.L.U.E (Claims History) and MVR checks to confirm my insurance information history for myself, family and any household members. No Obligation Life Proposal No Obligation Short Term/Long Term Disability Proposal Accept Reject Accept Reject Signature: Date: Phone Confirmation : () Agent Initials: 24/24 Service Pledge

3 Named Insured/Spouse Address City / County State / Zip Code Phone Number Address Don-Rick Insurance Quote Opportunity Form (QOF) Are you being non-renewed by your current insurance carrier? Have you filed bankruptcy in the last 7 years? Info If Yes Has there been Claims, Accidents, or Violations in the last three years? Description if Yes Date Amount Paid (If Claim) How Long Have you lived at this address? If less than 3 Years-Prior Address(s) : How Many People Live in the Household (whether or not Insured) List all Household Members 15 years of age or older Name (First, Middle Initial, Last) DOB DL# (If Auto Quote) SS# Child away at School 100+ Miles Good Student Discount (GSD): If GSD, Names: Other Info: _

4 Auto Proposal Info Don-Rick, Inc. Ca r 1 Vehicle Information Make Model Veh Use Yr (Ford) (Taurus) VIN W/ P Miles To Work Driver Driver Occupation s Education Level College/Alumni Assn. Member Y/N If Yes, Name: Any Vehicle Used for any business activity for yourself or for others? Extended Non-Owned Auto Liability Coverage Needed? Non-Household Members Permitted Regular Use of Any Auto? Any Non-Factory Installed Accessories on any Vehicle? Any Campers or Trailers? Any Vehicles Garaged Anywhere other than at Primary Residence If Yes, Details: Liability Bodily Injury/Property Damage $50/100/50 $100/300/100 $150/300/100 $250/500/100 $500/500/100 Other Present Coverages Medical Payments Rejected $5000 $10,000 $20,000 $25,000 Other Uninsured & Underinsured Motorists $50/100 $100/300 $150/300 $250/500 $500/500 Other

5 Comprehensive Deductible Collision Deductible Rental Car Towing Car 1 Car 1 Car 1 Car 1 Car 2 Car 2 Car 2 Car 2 Car 3 Car 3 Car 3 Car 3 Car 4 Car 4 Car 4 Car 4 Car 5 Car 5 Car 5 Car 5 Loss Payee & or Gap Coverage Necessary? Car 1 Car 2 Car 3 Car 4 Car 5 Other Info: Life/Disability/LTC/Annuity Option In our effort to fully protect you we need to know how you feel regarding the protection of your family in these areas. Would you be interested in a Life Insurance proposal for you or a family member including the new kind that gives you you re money back if you don t use the insurance? Would you be interested in insuring your paycheck with a Disability Insurance proposal? Are you interested in a Long-Term Care proposal in the event you are unable to care for yourself or a family member? Are you interested in an Annuity investment? If age 65 or nearing 65, are you interested in Medicare Supplement Coverage Information? Homeowners/Renters/Condo Proposal Info - Don-Rick, Inc.

6 Note-For Renters/Condos Proposal Complete Questions with (*) Special Items/Updates Y/N or # Y/N or # Year/% *Hot Tub Plumbing- Yr of Update *Trampoline *Pets & # *In Home Bus. * Daycare/FosterCare & # of Children Sliding Glass or French Doors Skylights # of Bathrooms * 100Amp Electrical Service/Breakers or Fuses Any known Knob & Tube or Aluminum Electrical In Dwelling? Solar, Wind or Any Alternative Energy Source Standard/Custom Bath Standard/Custom Kitchen * Security/Fire Protection System Special/Custom Wall Coverings O Primary Location O Secondary Location (Physical Address) O Vacant O Foreclosure O Short - Sale Notes: *Construction Type Square Footage Living Area * Yr Built Style & # of Stories / Foundation Type/Material & % if More Than One Basement Full/Slab % Walkout? Yes / No Finished % Type of Siding & % if More Than One Garage Attached/Detached -Size Porches/Decks & Sq. Ft. *Type of Roof /Age * Type of Primary Heat/Age Central Air Y / N * Any Unsecured Porches, Decks or Steps with no Railing? Yes / No If Yes, Details Interior Wall & Ceiling Materials Type of Floor Coverings & % if more than one *Mileage to & Name of Primary Fire Station * Distance to Nearest Hydrant Acreage of Primary Location? *# Of Units in Building *Within City Limits? Y / N * If No, in Subdivision or Cluster? Y / N How Many Homes? * Alt. Heat Source Y / N Fireplace - Fireplace Insert - Wood Stove Corn/Wood Pellet - Outdoor Furnace Location Of Alternate Heat Source? # Of Outbuildings Any Outbuildings with a Heat Source Yes / No Pool On Premises? Y / N Above Ground / In Ground Diving Board? Y / N Depth below Board? Type: Fencing around Pool/Premises w/ locking Gate? Y / N Slide Present? Y / N Depth below Slide?

7 * Any Other Owned Property? Yes / No If Yes, Number of Parcels, Acreage and Descriptions: * Incidental Farming? Yes / No If Yes, Details: Farm Type Animals? Yes / No Type & How Many: Any Owned Properties for Sale? Y/N If yes, describe Present Limits Dwelling Other Structures *Personal Property *Personal Liability *Deductible Medical Payments *Do you have any items that should be scheduled? Can eliminate deductible and cover breakage, mysterious Disappearance and does not reduce Coverage C Limit (Ex. Jewelry, Fine Arts, Guns) *Do you have any recreational or self-propelled toys or vehicles? If yes, please describe and provide values and CC s or Horsepower ratings. Do you have any interest in Coverage for Water Damage for Below the Surface of the Ground or Flood? Do you have or want a personal umbrella? - If Yes, limit (Recommended for Everyone) * Any Claims, Last 5 Years? (At This Location or Any Other Location) Mortgagee Info: First Mortgagee: Second Mortgagee: Third Mortgagee: Other Important Info: 03/11/2014