AUTOMOBILE INSURANCE CHECKUP WORKSHEET

AUTOMOBILE INSURANCE CHECKUP WORKSHEET

DATE:

Name(s):
 
Address:
 
Telephone:
E-mail:
Employer:
Position:
Children/Ages:
1.   List the make, model and year of each vehicle that you currently insure:
    
2.   Identify your current automobile insurance company:
    
3.   Do you own your home?      Yes.      No.
4.   Do you own any other
      residences?		      Yes.      No.
5.   What is your household's approximate gross income for this year?
    
6.   What is your household's approximate net worth?
        Below $100,000          $500,000-$1,000,000
         $100,000-$250,000          Above $1,000,000
        $250,000-$500,000  
7.   Do any of your children have driver's
      licenses?     		 Yes.        No.
8.   Do any relatives reside with you?      Yes.        No.
9.   If so, do any of these relatives own vehicles
      which are not covered by your automobile
      insurance policy?		 Yes.     No.
10.  Do you have medical insurance?      Yes.           No.
11.  Do you have a private disability insurance
       policy?     		 Yes.           No.
12.  Current bodily injury liability limits (review declaration page):
       Per Person: $ 
       Per accident/occurence:      $ 
13.  Current personal injury protection (PIP or no fault) benefits:
       Any Deductible:     
       Additional PIP benefits:     
       Managed care option:     
       Property damage:
       Wage loss benefits:     
       Death benefit/funeral
       expense:     
       Alternative provider
       service:     
14.  Uninsured Motorist Benefits:
       Per Person :     
       Per accident/occurence:     
       Stacked/Non-Stacked:     
15.  Uninsured Motorist Benefits:
       Per Person :     
       Per accident/occurence:     
       Stacked/Non-Stacked:     
16.  Collision Loss Coverage:
       All Vehicles:
       Deductible:     
17.  Comprehensive Loss Coverage:
       All Vehicles:
       Deductible:     
18.  Towing and Labor Coverage:
       At least 1 hour towing
       expense:     
       Emergency Service :     
19.  Rental Reimbursement:            Yes.        No.
       If yes, how much allowed
       per day? 
20.  Umbrella Coverage:  

 

NOTES:    
   

You may when done, or if you want to start over.