If you do not currently carry auto coverage with us, would you like a quote?

☐ Yes

☐ No

Are you interested in increasing your liability limits?

☐ Yes

☐ No

Would you like us to review your uninsured / underinsured motorist limits?

☐ Yes

☐ No

Would you like a quote for inclusion of electronic devices not permanently installed? (GPS, stereo system and media, two-way radio, antenna, travel trailer, pop-up campers with awnings, customized equipment or the camper unit/shell for your pickup or van)

☐ Yes

☐ No

Do you have any vehicles furnished for your regular use that you do not own, such as a company car?

☐ Yes

☐ No

Have any vehicle titles been changed to another party or to a trust?

☐ Yes

☐ No

Vehicles not listed on your policy may be EXCLUDED from coverage. Do you own any vehicles not listed on your policy that should be?

☐ Yes

☐ No

Drivers not listed on your policy may be EXCLUDED from coverage. Are there any household members not listed on your policy? Are there any non-household members who regularly use your vehicle(s)?

☐ Yes

☐ No

If your vehicle is financed (or leased), is the lienholder or leasing company properly listed on the policy?

☐ Yes

☐ No

Is your vehicle used for business?

☐ Yes

☐ No

Is your vehicle used to drive for Uber, Lyft, or another ridesharing company?

☐ Yes

☐ No

Is your vehicle used to deliver pizza, food, groceries, etc.?

☐ Yes

☐ No

Would you like a quotation for rental reimbursement coverage or towing & labor coverage in the event your vehicle is damaged in an accident?

☐ Yes

☐ No

Do you have any recreational vehicles (motorbikes, motor homes, golf cars, Mopeds, ATVs, snowmobiles, etc.) that should be insured?

☐ Yes

☐ No

If you do not currently carry homeowner’s coverage with us, would you like a quote?

☐ Yes

☐ No

Has the insured property been deeded to another party or to a trust?

☐ Yes

☐ No

If you have a mortgage, is the mortgage information shown on your policy correctly listed?

☐ Yes

☐ No

Due to inflation and increased costs of construction, property values should be examined annually. Are your home and personal belongings coverages insured for 100% replacement value?

☐ Yes

☐ No

Is your property part of a homeowner’s association?

☐ Yes

☐ No

Does your home have a monitored fire and/or burglar alarm system?

☐ Yes

☐ No

Have you updated the roof of your home? If so, when?

☐ Yes

☐ No

Have you updated the electrical wiring, plumbing, and/or heating/AC?

☐ Yes

☐ No

Do you have any valuables such as: jewelry, silver, furs, camera equipment, money, fine arts, firearms, or other items that should be insured separately due to limited or no coverage on your policy?

☐ Yes

☐ No

Would you like a quotation for backup of sewer and drain coverage?

☐ Yes

☐ No

Flood coverage is NOT included on standard homeowner’s policies. Would you like a quotation for this important coverage?

☐ Yes

☐ No

Wind coverage MAY or MAY NOT be included on standard homeowner’s policies. Would you like a quotation for this important coverage?

☐ Yes

☐ No

Catastrophic limits may or may not match the limits you carry on your property. If you already have flood or wind coverage in place, would you like a quotation for limits in EXCESS of what you currently carry?

☐ Yes

☐ No

Earthquake coverage is NOT included on standard homeowner’s policies. Would you like a quotation for this important coverage?

☐ Yes

☐ No

Ordinance and law coverage is NOT usually included on standard homeowner’s policies. Would you like a quotation for this important coverage?

☐ Yes

☐ No

Mold remediation is NOT usually included or may be limited on standard homeowner’s policies. Would you like a quotation for this important coverage?

☐ Yes

☐ No

Identity theft coverage may be available. If available, would you like a quote?

☐ Yes

☐ No

Are you interested in higher limits of liability?

☐ Yes

☐ No

Would you like a quotation for personal injury coverage?

☐ Yes

☐ No

Do you own a secondary home, rental income property, or any other property?

☐ Yes

☐ No

Do you own any vacant land?

☐ Yes

☐ No

Do you work, maintain, or operate a business, give private lessons in your home? (Includes but not limited to baby-sitting, lawn mowing, Tupperware, Mary Kay, Avon, etc.)

☐ Yes

☐ No

Are you presently involved in any form of farming or ranching?

☐ Yes

☐ No

Do you rent any portion of your home to others on a regular or temporary basis?

☐ Yes

☐ No

Do you or any residents in your household have any pets? If so, what kind?

☐ Yes

☐ No

Children living away from home, including away at school, MAY NOT be covered. Do you have any children living away from home or away at school?

☐ Yes

☐ No

Do you own any aircraft, model aircraft or hobby aircraft (e.g. drone)?

☐ Yes

☐ No

Do you own any watercraft?

☐ Yes

☐ No

Do you have any electric, battery, or gas powered children vehicles? If yes, would you like a quotation for coverage?

☐ Yes

☐ No

Do you or any resident of the household hold any elected or appointed position or serve on a Board of Director?

☐ Yes

☐ No

If you are a Condominium Owner, have the condo association by-laws changed or has the deductible under the master association policy changed?

☐ Yes

☐ No

If you do not currently have Loss Assessment coverage or are not carrying the maximum limit, would you like a quote or a quote to increase?

☐ Yes

☐ No

Is there anything else that has changed, or that you think may affect your insurance coverage? If yes, please explain.

☐ Yes

☐ No

Would you be interested in an umbrella policy that extends your automobile and homeowner’s liability coverage to $1 million or more?

☐ Yes

☐ No

Do you retain household employees? If yes, please explain.

☐ Yes

☐ No

Notes/Comments:

☐ Yes

☐ No

Signature:

Date:

Compensation. In addition to the commissions or fees received by us for assistance with the placement, servicing, claims handling, or renewal of your insurance coverages, other parties, such as excess and surplus lines brokers, wholesale brokers, reinsurance intermediaries, underwriting managers and similar parties, some of which may be owned in whole or in part by Brown & Brown, Inc., may also receive compensation for their role in providing insurance products or services to you pursuant to their separate contracts with insurance or reinsurance carriers. That compensation is derived from your premium payments. Additionally, it is possible that we, or our corporate parents or affiliates, may receive contingent payments or allowances from insurers based on factors which are not client-specific, such as the performance and/or size of an overall book of business produced with an insurer. We generally do not know if such a contingent payment will be made by a particular insurer, or the amount of any such contingent payments, until the underwriting year is closed. That compensation is partially derived from your premium dollars, after being combined (or “pooled”) with the premium dollars of other insureds that have purchased similar types of coverage. We may also receive invitations to programs sponsored and paid for by insurance carriers to inform brokers regarding their products and services, including possible participation in company-sponsored events such as trips, seminars, and advisory council meetings, based upon the total volume of business placed with the carrier you select. We may, on occasion, receive loans or credit from insurance companies. Additionally, in the ordinary course of our business, we may receive and retain interest on premiums you pay from the date we receive them until the date of premiums are remitted to the insurance company or intermediary. In the event that we assist with placement and other details of arranging for the financing of your insurance premium, we may also receive a fee from the premium finance company.

If an intermediary is utilized in the placement of coverage, the intermediary may or may not be owned in whole or part by Brown & Brown, Inc. or its subsidiaries. Brown & Brown entities operate independently and are not required to utilize other companies owned by Brown & Brown, Inc., but routinely do so. In addition to providing access to the insurance company, the Wholesale Insurance Broker/Managing General Agent may provide additional services including, but not limited to: underwriting; loss control; risk placement; coverage review; claims coordination with insurance company; and policy issuance. Compensation paid for those services is derived from your premium payment, which may on average be 15% of the premium you pay for coverage, and may include additional fees charged by the intermediary.

Questions and Information Requests. Should you have any questions, or require additional information, please contact this office at 214-301-3333 or, if you prefer, submit your question or request online at http://www.bbinsurance.com/customerinquiry/