Brandon Jones Insurance Agency Questionnaire Date:

Name:____________________________ Source? ________________________

Address:___________________________ Umbrella? Y___N___

____________________________ Health coverage for all members of family? Y___ N___

*Home (____)_____________*Work(____)_____________*Cell (____)_____________*Email _____________________

Current Insurance Co?__________________X-Date(auto)___________X-Date(home)__________ How long?________

Name DOB DL# Good SSN # # Ticket(s) # Accident(s) Employer/

Stud. -5 years -5 years
? Occupation/Annual
Income

Children

VIN: VIN: VIN:

Year Make Model Year Make Model Year Make Model

Work:1 Way ____ Work:1 Way ____ Work:1 Way ____

Odometer: __________ Odometer: __________ Odometer: __________
Days of Commt______ Days of Commt_______ Days of Commt_______

Current Coverages Current Coverages Current Coverages

BIPD BIPD BIPD
UIM UIM UIM
PIP/Med PIP/Med PIP/Med
Comp Comp Comp
Collision Collision Collision
Tow Tow Tow
Rental/K-cov Rental/K-cov Rental/K-cov
Glass BB Glass BB Glass BB
*Leinholder: *Leinholder: *Leinholder:
Vehicle Vehicle Vehicle 3/Driver__________________
1/Driver__________________ 2/Driver__________________

Boat Motorcycles Campers,Trailers,Motor

Year_________ Make____________________ Year_________ Make____________________ Year_________ Make____________________
Model________________________________ Model______________# Yrs Lic?___________ Model________________________________
_ _
Serial # _______________________________ VIN#__________________________________ VIN#__________________________________
Length___________ HP______ CC ______________ Type__________________________________
In/Out?__________ Current$?___________ Type__________________________________ Price New $____________________________
HIN_________________________________ Value________ Special Equip Value________
 Homeowner

Year Built_______ Sq. Ft._________ Stories?_____ Roof Type: Comp__ Wood__ Tile__ Other__ Roof Age: _____

# Baths______ # Fireplaces_____ Gas?____ Masonry?____ # Garage_____ Attached: Y__ N__

Market Value$__________ Basement: Y or N / Finished %____ / Walk-out: Y__ or N__ Air Conditioning: Y__ or N__

Balcony: Y__ or N__ Deck: Y__ or N__ / Material__________

#Skylights_____ #Sliding Glass_____ #Bay Windows_____ # French Doors? _______

Exterior Walls: %Wood Siding________ %Stone_________ %Brick_________ %Other____________________

Interior Walls: %Paint________ %Paneling________ %Paper________ %Other____________________

Floor: %Carpet________ %Hardwood________ %Vinyl________ %Tile________ %Other____________________

Alarm: Central_____ Local_____ None_____ Laundry Room Location? _____________ Sep. Structures? ___________

Renter

Year Built __________ Type: House or Apt (# of Units) ________ Personal Property $____________________

1) Dogs? ___________________Bite History Y / N

2) Last property claim? Date and Amt.(5
Years)________________________________________________________
3) Guns, or silver / gold-ware over $3000? Computers $5000?____________________________________________
4) Jewelry over $1000/single item or $5000 in total? ___________________________________________________
5) Any debris on the premises? ____________________________________________________________________
6) House under any renovation or repair? ____________________________________________________________
7) Pools, Business Property, Collections, _____________________________________________________________

Current Insurance Information

Current Insurance Company ____________________________________________________

Dwelling _________________________ Personal Liability ____________________________

Deductible _______________________ Med Payments _____________________

Other coverages (Jewelry, computer, guns, earthquake) ____________________________________________

Life

Ht:_____ Wt:_____ Smoker: Y__N__ Health Cond:___________ RX?_____________________

Ht:_____ Wt:_____ Smoker: Y__N__ Health Cond: __________ RX?_____________________

Mortgage_______________ Auto Loans_______________ Student Loans__________________ CC________________

Refinancing? Y N Purchasing/Selling Home Y N Notes:____________________________________________________