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Personal Insurance Review

You deserve an attentive insurance agency that cares that you have the right insurance protection. Please take 5 minutes to share, confirm and update your information. This form helps us identify potential discounts and other coverage issues that should be discussed.

Contact Information












Changes in your life/work

Change of address, recent or upcoming?



Change in marital status, recent or upcoming?



Any new kids in the family?



Changed jobs recently?



Anyone work out of a home office?



Anyone in household self-employed full- or part-time?



Hire anyone to work in your home such as a nanny, a housekeeper, a caregiver, etc?



Anyone create or post content for a website or a blog for work/pleasure?





Review specific needs

To help avoid gaps in coverage, please provide information even if you have policies through a different source.

Vehicle Coverage Considerations:

Any new drivers in your household?



Garaging address changed and now different from home address?
*garaging means location where a vehicle is primarily parked overnight



Any vehicle(s) have customized equipment permanently installed?



Recently paid off a loan on your vehicle?



Any vehicle used for any business purposes?



Use a company car that you don't own?



Anyone not listed as a driver on your policy use your vehicle(s) regularly?






Discounts and potential savings considerations:

You or your spouse/partner have an auto policy elsewhere?



Consider increasing your deductible to lower your premium?



Car(s) have anti-theft device(s) of any type?




Member of a motor club, i.e. AAA, GM Motor Club, Onstar, etc.?



Low annual mileage on any of your vehicle(s)?




Use public transportation to commute to work on an ongoing basis?



A student on your policy lives away at school at a distance of 100+ miles?




A student on your policy has a grade average of "B" or 3.0 or higher?



A driver has completed an approved advanced driver training program?



Are you currently on an automatic payment plan?



...If not, would you be interested in automatic payments to receive a discount?



Do your home and auto liability limits cover your assets (home equity, retirement, savings, etc.)....



Coverage options and special endorsement considerations:

Let us know if you're interested in any of the following:

Towing and labor for a disabled vehicle



Rental/substitute transportation in the event of an accident



Auto loan/lease gap coverage*



New vehicle replacement value coverage*



Accident forgiveness policy feature*



Disappearing deductible for no accidents feature*

* Only available through certain insurance carriers.
Qualifying restrictions and limitations apply.



Home and valuables

Made any home improvements that you haven't informed us of?



Consider increasing your deductible to lower your premium?



Store business property at your residence or in your vehicle?



Have a second home or investment property home



Rent all or a portion of any properties that you own?



Have any valuable jewelry, guns, collectibles, etc. that we have not discussed?



Home is in a legal trust?



Recently paid off your mortgage?



Recreational vehicles:

Have a boat?



Other recreational vehicle(s)?



Agency Experience:





Additional coverage needs

Let us know if you would like more information or a quote.

Please Skip if you already have a coverage with us.

Informing us of policies you have elsewhere lets us help you avoid coverage gaps.

Personal umbrella liability policy:
extra protection over and above auto/home policies.





Auto insurance





Motorcycle insurance





Boat insurance





Homeowner, Condominium or Renter policy





Special coverage for high valued jewelry, fine arts, antiques, etc...





Water backup and sump discharge or overflow coverage





Earthquake insurance





Flood insurance





Business insurance





Life insurance - other than an employer provided policy





Fixed annuities





Long-term care insurance















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Childress Insurance Agency
2391 W Main St. Suite A Cabot, AR 72023
Phone: (501) 941-1148