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Auto Policy Protection Checklist

61% of claims Denied by insurance companies result from unreported changes and unreported property or vehicles.

Five minutes of your time to complete this auto policy protection checklist questionnaire will help eliminate claims problems.

There are no wrong answers and your response will enable us to discuss coverage concerns and provide recommendations for your auto insurance renewal.

Complete and submit the form below and a personal lines insurance agent will follow up with you to discuss your auto policy renewal.

We thank you for your business and look forward to hearing from you soon!

You can also print the form and mail or fax back to our office.

Auto Policy Protection Checklist

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Daytime Phone*
Daytime Phone*

Do we insure ALL the vehicles you own?*
Do we insure ALL the vehicles you own?*

	Yes
	No

Are any vehicles NOT registered or titled in you and/or your spouse's name?*
Are any vehicles NOT registered or titled in you and/or your spouse's name?*

	Yes
	No

If yes, which vehicle and whose name is on the title?

Has any vehicle been customized or altered?*
Has any vehicle been customized or altered?*

	Yes
	No

Would you be interested in obtaining information on a $1,000,000 umbrella liability insurance policy for as little as $3/week?*
Would you be interested in obtaining information on a $1,000,000 umbrella liability insurance policy for as little as $3/week?*

	Yes
	No

If you own a pickup or van, does it contain customized equipment, camper, or shell?*
If you own a pickup or van, does it contain customized equipment, camper, or shell?*

	Yes
	No
	N/A

Do you own a mini-bike, moped, motorized scooter, or motorcycle?*
Do you own a mini-bike, moped, motorized scooter, or motorcycle?*

	Yes
	No

Do you own any ATVs, boats, snowmobiles, SEADOO motor homes or trailers?*
Do you own any ATVs, boats, snowmobiles, SEADOO motor homes or trailers?*

	Yes
	No

Do you have any students away at college?*
Do you have any students away at college?*

	Yes
	No

Have you (or your spouse) changed jobs in the last 12 months?*
Have you (or your spouse) changed jobs in the last 12 months?*

	Yes
	No

If yes, how far are you (or your spouse) driving one way to your new job and in which car?

If you don’t already have “Rental Car Coverage”, would you like to have a rental car provided for you if you get in an auto accident for about $20 per year per car?*
If you don’t already have “Rental Car Coverage”, would you like to have a rental car provided for you if you get in an auto accident for about $20 per year per car?*

	Yes
	No
	Already Have Coverage

Is there anyone that lives in your house that is not listed on your auto policy? *
Is there anyone that lives in your house that is not listed on your auto policy? *

	Yes
	No

If yes, what is their name, birthday and relation to you?

Do you have a teenager that is going to be getting a permit in the next year?*
Do you have a teenager that is going to be getting a permit in the next year?*

	Yes
	No

If yes, name and birthday?

If you don’t already have “Road Side Assistance” would you like to add it for about $6 per car per year?*
If you don’t already have “Road Side Assistance” would you like to add it for about $6 per car per year?*

	Yes
	No
	Already Have Coverage

Are any of the cars on your policy used for any type of business use?*
Are any of the cars on your policy used for any type of business use?*

	Yes
	No

If yes, how are they used?

Would you be interested in getting a quote for life insurance to protect your family in case of your early death?

	Yes
	No
	Already Have Coverage

Do you have any questions about your renewal?

List any additional information that may assist us

Please enter the word that you see below.

From Auto Policy Protection Checklist to Brown-Phillips Insurance home

Brown Phillips Insurance is independently owned and operated.
Insurance licensed in North & South Carolina & Georgia.
4940-B Windy Hill Dr., Raleigh, NC 27609 Phone 919-874-0405
Charlotte Area 704-255-1710 • Triad Area 336-450-2727
To view privacy policy: Click Here.

SBI!