FamilyNeedsEval

...Family Insurance Needs Evaluation

At Kapnick Insurance Group we recommend an annual review of all your insurance policies. This form will help to make your review as quick and efficient as possible. Please take a moment to answer the questions and submit this form to us. After reviewing the information you have submitted, a client service representative will contact you to answer any questions regarding your current policies and make recommendations.

You can review your current policy information online with Policy eServices, which provides policy details including current limits and deductibles. To access this system, call our toll free number, 888.263.4656 and select option #3, ask for a Policy eServices password, and you will be emailed the password within 24 hours.

Please note:
- Optional coverages may result in an increase in your insurance premium.
- If there is no response to this evaluation, the carrier will renew based upon the previous information on file.

PROPERTY INSURANCE
After reviewing your current policy limits, do you feel that you could rebuild, repair or replace all of your property and contents if you suffered a loss? Yes No

Purchasing higher limits than standard policy coverage can protect your assets. Please review the list below and check the ones for which you need further information:
Building Other Structures Personal Liability Back-up of Sewer	Identity Theft Personal Property Additional Living Expense Medical Payments	Ordinance of Law Flood Firearms Personal Computers	Unscheduled Property Silverware/Goldware Farming Earthquake Mold

LIABILITY EXPOSURES
Check any of the following that you own:
Trampoline Swimming Pool Hot Tub or Sauna Daycare Business in Your Home Dog - please list breed Domestic Staff: . Yes .. No If yes, would you be interested in a Work Comp policy? Yes No

VEHICLE
You can purchase higher limits, increase coverage by endorsement or modify deductibles. Please review your limits and check the items for which you want further information:
Bodily Injury Comprehensive Road Service	Property Damage Collision Medical Payment/Personal Injury Protection	Uninsured/Underinsured Motorist Rental Reimbursement

Additional Exposures - do you own any of the following:
Boat Motorcycle Golf Cart	Airplane Snowmobile Travel Trailer	Antique Vehicle ATV Utility Trailer

Are all vehicles titled in your name? Yes No
Do you have a furnished vehicle for regular use? Yes No

ADDITIONAL PROTECTION
We provide protection for many exposures. Please indicate if you are interested in receiving information on the following: Life Insurance: We offer a full-time staff devoted to helping you with life insurance needs. Do you own any Life Insurance other than employer-provided? Yes No Would you like a no-obligation complete analysis of your current plan? Yes No I would like information on Personal Umbrella Insurance - providing $1,000,000+ liability protection.

CONTACT INFORMATION
Name Phone Address City State Zip Email Address

ADDITIONAL COMMENTS

Thank you for taking the time to complete this review. Please click here to submit your information