Free Personal Lines Coverage Review (Home/Auto) @ Thoroughbred Associates

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Thoroughbred
Associates

E-mail: awinkie@thoroughbred
associates.com

Phone: 1-502-245-7841
Fax: 1-502-245-3811
Toll Free: 1-800-219-8211

Personal Lines (Home/Auto) Coverage Review Request: One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your Name (First, Last)

E-Mail (REQUIRED):

E-Mail (again to verify accuracy):

Phone (REQUIRED):

Your Policy Number (s): (If available)

Review Section
Do You own more than $1,000 of any of the following? (Check ALL that apply)	Jewelry, including watches Furs Trading Cards Stamps Valuable Papers Securities & Other

Do You own more than $2000 of firearms?	No Yes

Do You own more than $2500 of silver, silverware, or golfware?	No Yes

Do You have valuables such as antiques, fine art, photography equipment, or sporting goods?	No Yes

Do You have Alarm System(s) installed in your home?	No Yes

Are your personal belongings insured for their FULL replacement value?	No Yes

Do you operate a business, office, studio, or any income generating hobby from your home?	No Yes

Have you recently remodeled or redecorated your home?	No Yes

Are you interested in coverage against flood, backup of sewers or drains, or sump pump failure?	No Yes

Do you own a second residence, rental property or investment property?	No Yes

If you rent, do you already have renter's insurance?	No Yes (Not a renter)

Please list the year(s), Make(s) and Model(s) of ALL vehicles in your household: (Also, please complete the 1 way mileage to work, and business use questions below each vehicle.)	#1 Miles Driven to work? Business Use? No Yes #2 Miles Driven to work? Business Use? No Yes #3 Miles Driven to work? Business Use? No Yes #4 Miles Driven to work? Business Use? No Yes

Are you the registered owner of all vehicles above? (If not, please list in remarks)	No Yes

Please list ALL drivers in your household: (and include birthdates, and driver's license #'s if possible)	#1 #2 #3 #4

Are any of your cars modified from what was purchased at the dealership?(list in remarks)	No Yes

Do you have rental car reimbursement on all of your autos?	No Yes

Do you own any recreational vehicles? (i.e., boats, jet skies, trailers, etc.)	No Yes

Do you have an Umbrella or Extended liability policy now?	No Yes

Do you own a business?	No Yes

May we offer you a review of your Life, Health, or Disability insurance?	No Yes, Please Do!

List any comments or special instructions here:

If we need further information, how should we contact you?	Fax E-Mail Regular Mail Please Call Me!

Thank you for filling out this form COMPLETELY!
We deem your data submitted as PRIVATE information. Every step has been taken to insure your privacy, security, and to release this information only to you. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Also, the insurance carriers reserve the right to issue coverage or not, and we cannot guarantee acceptance of a risk until approved by the company.
Yes, Please review my personal insurance, and contact me if any changes or revisions may be needed!

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