Home & Auto Insurance Review Confirm Personal InformationName of individual completing this form: First Last Best phone number to reach you:Email: Marital status: single married If married, indicate spouse's name: Occupation: Spouse's occupation, if applicable: Home InsuranceCurrent Mortgage Company & Loan NumberNew Business Activities in Your HomeIs there any business activities operated by anyone out of your home: (ie: babysitting, music lessons, nail salon, home-based office etc..) Yes No If yes, please indicate type of business:New Additions or RenovationsYear roof has been replaced Roofing Material Asphalt Shingles Tile (Ceramic or Tile) Steel/Metal other Updates to:WiringPlumbingHeating/ACSiding Please check applicable Basement finish Home remodel Sump pump Deck Fence Hot tub Swimming Pool Trampoline Garage Solar Is your home still occupied by you? Yes No Do you rent out any portion of your home, garage, or property (including Air BnB, etc?) Yes No Newly Purchased Valuable PosessionsIndicate New purchases or valuable possessions: Rental Property Boat Musical Instruments Silver/silverware Fine Art Furs Snowmobile/ATV/Dirt bike Jewelry Computer/laptop Golf cart Firearms Collectibles (stamps, coins, etc.) Hearing Aid Security InformationNote: There maybe discounts available, based on the information provided. Please indicate what applies to you: Central Alarm System (ie. alarm monitored by a 3rd party) Burglar Alarm Fire Alarm Fire Extinguisher Miscellaneous InformationI have dogs located on my property: Yes No If yes, indicate type of dog breed , and number of dogs: If yes, has your dog(s) ever bitten anyone? yes No I Regularly employ a nanny, maid/housekeeper, lawn care employee, or child care/elder care employee in my home: Yes No Auto InformationTo ensure proper coverage, please indicate which of the following apply to you: I have a new household member or licensed driver. If yes, please list name, date of birth, driver's license#, and indicate which vehicle he/she uses: My vehicle is used for: Delivery (pizza, Uber/Lyft, etc) Business use If business use, please describe: Have you purchased in the last year or do you own one of the following items? RV (camping trailer, 5th wheel, etc.) Motor home Utility trailer Motorcycle Boat/Watercraft Other Insurance NeedsBolder Insurance would be happy to discuss your insurance needs in more detail. Please indicate any topics of interest to you: Increased Personal Liability Limits (for instance Auto, Home, or Umbrella) Insurance for your Business needs Business auto insurance Life Insurance Home Auto Flood Insurance Earthquake Insurance Other (describe) Δ
