Did you know that 37% of all unpaid Homeowner claims are denied because of unreported changes! Five minutes of your time to complete this checklist will help to eliminate claim problems.

Don’t forget to reference the enclosed Summary of Insurance as this will help you to answer some of the questions dealing with your current coverage.

There are no wrong answers and your response will enable us to discuss coverage concerns and provide recommendations. We understand that you may already have coverage in some of these areas. Your answers will help us to understand your desires in the event of a loss.

Yes No

1. Have you recently had any changes in your home address, employment or marital ______

status?______

2. Please see the enclosed Summary of Insurance that will indicate the insured value ______

of your dwelling (house), other structures (detached garages and outbuildings),

and personal property (contents). Are you sure that this is enough coverage in the

event of a fire, tornado, etc?______

3. Please review your mortgagee (if any) on the enclosed Summary of Insurance. ______

Do any changes or updates need to be made?______

4. Have you recently remodeled your home, added any additions, built outbuildings ______

or garages, finished a basement, etc. with a cost of over $5,000 that have not been

reported to us? If so, please indicate the change and the cost of construction.

______

5. Have you recently updated the following: heating/ac, plumbing, wiring, roof ______

(please circle and provide year): ______

6. In order to make sure that you are receiving maximum discounts, please indicate ______

if you have the following in your home: smoke detector, fire extinguishers, dead

bolt locks, burglar alarm (central station or local), and fire alarm (central station

or local). Please circle.

7. Some insurance companies provide premium reductions if you are over age 50. ______

Are you? If so, what is your date of birth and social security number? ______

8. Would you definitely consider increasing your deductible (see enclosed Summary ______

of Insurance) to lower your premium? ______

Yes No

9. Danger! Every insurance policy has internal sum-limits. I own some of the ______

following and need a quote for scheduling these on my policy:

**Please be sure to reference the enclosed Summary of Insurance to see if any of these items have already been scheduled on your policy.

Jewelry $______Antiques $______Guns $______Furs $______

Fine Arts $______Silverware $______Goldware $______

Collectibles $______Home Computer $______

Coin or Stamp Collection $______Camera or Photo Equipment $______

Money/Bank Notes/Bullion/Gold $______

Securities/Accounts/Deeds/Letters of Credit $______

Property used for Business Purposes on Premises $______

Property used for Business Purposes away from Premises $______

10. Warning! Your Homeowners Policy does not automatically provide coverage for ______

flood. Most people think of rising streams, lakes, rivers, and oceans when they

think of flood. But 76% of all flood claims are caused by a large amount of

rainfall in a short time period that causes standing groundwater to infiltrate your

house. Do you want a quote for flood insurance?

11. Warning! Your Homeowners Policy does not automatically cover Earthquake. ______

Many areas in Nebraska are right on top of fault lines and the damage could

be severe. The rates for Earthquake coverage are approximately $.60 per $1000

of building value for masonry homes and .30 per $1,000 of building value for

non-masonry homes. Do you want a quote for earthquake insurance?

12. Do you own the following (please circle those not already listed on enclosed ______

Summary of Insurance): new primary residence, vacation home, condominium,

rental property, investment property, boat, jet ski, airplane, recreational vehicle

(ATV, go-cart, motorcycle, golf cart, etc.) that is not already listed on the

enclosed Summary of Insurance. Please circle above if you would like a quote to

cover both liability and damage to property.

13. Danger! Business conducted at your home is not automatically covered if you ______

get sued including home based businesses, studios, offices, private lessons, and

baby-sitting. Do you conduct any business on your premises?

______

Yes No

14. Do you have any children away at college? Living in a dorm? Off campus? ______

Do they have a vehicle with them? Attending full-time? ______

15. Do your children have private jobs like babysitting or mowing grass? ______

______

16. Do you have anyone employed, for example, a nanny, housekeeper, or yard ______

worker, who may need Workers’ Compensation coverage? ______

17. Do you rent any part of your home or other buildings on your property to anyone? ______

______

18. Do you own any vacant land or farmland? If so, does such land have any ______

improvements (dwellings, sheds, machinery, silos, wells, ponds, etc.) or any

farming, timbering, or mining operations in progress? Please circle any applicable.

19. Is your home or other property now titled in a trust, LLC, corporation, ______

partnership, or in the name of someone other than you or your spouse? The new

titleholder is ______.

20. Are you a coach, committee member, or board member? ______

21. Do you own any animal that could bite someone or cause a lawsuit? ______

If so, what kind ______

22. Do you own a trampoline or swimming pool? ______

23. Do you want to be covered in case of identity fraud? ______

We can provide up to $15,000 for expenses incurred due to identity fraud.

24. If your net worth is more than the limit of your Homeowners Liability (see ______

enclosed Summary of Insurance)? Would you pay $2 or $3 per week to have it

protected by buying an Umbrella policy?

25. Do you own a business not insured by us? When does that insurance renew? ______

Can we contact you then? ______

26. If you were to be confined to a nursing home or require home health care due to a ______

serious injury or sickness would you want the insurance company to pay the

$40,000 per year bill? If so, would you be interested in purchasing a Long Term

Care policy? ______

27. Do you want your home paid for by the insurance company in the event of death? ______

If you marked yes, would you like an agent to contact you for a free quote? ______

28. If you get sick or injured and can’t work for 7-13 weeks or longer, would you like ______

the insurance company to make your car and/or house payments?

If you marked yes, would you like an agent to contact you to show you how? ______

29. With whom do you have your life insurance now? Could we review your policies ______

for you? Would you like a free quote for additional insurance?

30.  What is your latest e-mail address? ______

Yes No

31. Do any changes need to be made to update the enclosed Summary of Insurance? ______

32. Would you like to schedule an appointment for a phone review or in-office visit ______

to discuss your insurance program? If so, please list a convenient time:

______.

This Form was completed by: ______

Signature: ______

Date: ______Home Phone: ______Work Phone: ______

This simple review can help to prevent claim problems. Thank you for your time and cooperation! We appreciate your business and hope that you tell you friends and neighbors about us when talking about insurance!