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Personal Insurance Survey Questionnaire

To assist us in analizing your personal risk management and insurance needs, please complete this survey/questionnaire. (Required fields are marked with an asterisk (*).

Personal Info

*First Name:   *Last Name:     Spouse:

Address:      *City:      

State:      Zip+4: -      *Email:

*Phone: - -     Best Time to Call:


Homeowners and Renters
Yes No  
Are you sure that you are insuring your home to its full replacement cost?
Do you own any antiques or fine arts?
Do you own more than $2,500 in silverware, goldware or pewterware?
Do you have any collections such as unique dishes, post cards, clocks, dolls stamps, coins, etc.?
Is the total of all your jewelry, watches and furs valued over $1,000 or $500 for one item?
Do you need more than $2,000 of theft coverage for all your guns?
Do you own any business personal property or tools used in your occupation?
Do you want your money covered for more than $200?
Do you want coverage for damage done by water backing-up through sewers, drains or sumps?
Do you want your contents insured for Replacement Value?
Do you have a fire or burglary detection system in your home? 
    If so, what type?
Do you own or lease any property other than your home?
Are you engaged in any farming or ranching?
Do you conduct any business or give private lessons in your home?
Are you sure you have enough Personal Liability insurance?
Would you like a quotation on coverage for damage done by surface water or flooding?
Would you like to save on your insurance premiums by increasing your deductible to the next level?
Would you like us to send you a form to assist you in making an inventory of your contents? 
Do you anticipate moving soon?

Automobiles and Other Vehicles
Yes No  
Does Coup Agency presently insure all of the vehicles in your household?
Are all of the licensed drivers in your household listed on your automobile policy?
Would you like to save on your insurance premiums by increasing your deductible to the next level?
Are you sure you have enough Auto Liability Insurance?
Do you have any students over 100 miles away at school, without having a vehicle with them?
Would any driver qualify for a good student discount with a “B” or “3.0” average or better?
Do you own a pickup or van with “customized equipment”?
Do you own any trailers?
    If so, what value?   What size?
Do you own any motorcycles, mopeds, four-wheelers or other motorized vehicles?
Do you have a vehicle, not your own, furnished for your use?
Would you like to discuss changing your “Tort” option?
Do you drive to work?
    How far do you drive each auto one way?
Would you like to review your Auto Medical, Work Loss, Funeral or Accidental Death benefits?
Do you want Towing and Emergency Labor cost coverage for your autos?

Other Personal Insurance Considerations
Yes No  
Do you have Income Insurance in case you are sick or disabled?
Are all members of your family protected adequately by Life Insurance?
Do you own a boat, plane or personal watercraft (i.e. Jet Ski or Wave Runner)
If you are over age 55 would you like a quotation on Long Term Care Coverage?
Would you like information on a retirement savings program or on a tax deferred annuity?
Would you like information and a quotation on Cancer Insurance?
Do you want information and a quotation on a Mortgage Cancellation Life Insurance policy?
If you are self employed, would you like a quotation on Health Insurance?
Are you interested in a quotation on business or professional insurance?
Would you like a quotation on our Medicare Supplement Coverage?

Please offer your questions, comments or suggestions:

If required, The Coup Agency will contact you to obtain the following information regarding each person in your household: Name, Date of Birth, Occupation, Place of Work and Social Security Number.

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By submitting this survey, you agree to be contacted by The Coup Agency for the purpose of providing insurance and/or financial assistance as requested.