Internal : Personal Lines Diagnostic Appointment Questionnaire Step 1 of 8 12% Let's Get StartedHi - My name is ____________. I want to let you know up front that we have a unique program that we have developed GRIT Insurance for our preferred personal lines clients. Over the past 20 years we have worked with hundreds of clients just like you. Our process starts with gathering some information to see if we can work together, then we complete a market analysis of our preferred insurance carriers and finally we put together a customized Personal Insurance Protection Package designed specifically for you and your needs in the event of small claim or catastrophic loss. We do this to get you the best value for your insurance. Your Personal Insurance Protection Package provides you the right insurance based on our conversation, providing prompt service to meet your needs at a fair price that will work within your insurance budget. While we can't fit everyone into our program I think it may make sense to spend about 20 minutes together to see if this plan is a good fit you and your insurance needs. Fair enough? Basic InformationFirst Named Insured First Last Second Named Insured First Last Primary Contact PersonFirst Named InsuredSecond Named InsuredSomeone ElseContact Person if not named insured First Last PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country BackgroundHow did they hear about our agency? If they found us on the internet - what did they search? If it was a referral - who referred them.How Long Have they lived in the area? (rappport building)When you decide to honor a company with your business what's the most important factor in your decision?Who do you have your insurance with now?How long have they had your business?When you purchased your insurance from them, why did you make the decisionto use them? (ANOTHER, VALUE SYSTEM . . . ALSO OPEENS TO POTENTIAL ISSUESTHAT MAY BE EXPLORED – FOLLOW UP QUESTIONS)Have they lived up to your expectations? (CLOSED QUESTION TO VALUE INCUMBENT)Other than cost, what would you like me to FIX about your current insuranceprogram? Why? (ALTERNATIVE OPEN QUESTION TO SEARCH FOR ISSUES – REMEMBER TO FOLLOW UP AND QUESTION DEEP)Have you had any problems with them, if so, how were they handled? (“I don’tsuppose …”) (OPEN QUESTION TO SEARCH FOR ISSUES – REMEMBER TO FOLLOWUP AND QUESTION DEEP)BudgetWhat is your current budget for your personal Insurance (ask for auto and home budget - we want to work within your current budget)What is your timeline for having us complete the market analysis for and present you with your options.?FINAL CONDITIONS OR RULES OF THE GAMEIs there any other reason why we could not do business together? (RULES OFTHE GAME QUESTION) Yes No Other Would you be interested in insurance recommendations to add protection you didn't have now if added only 10-20% to your current insurance budget?Can you help me understand how the final decision will be made? (DETERMINE WHO AND HOW)Are there any other conditions that must be met? POINT OF QUALIFICATIONIf we can fix the items we have discussed, is there any reason we shouldn’t continue to build a relationship? (CONFIRMING THE RULES OF THE GAME) Lines of BusinessLines of Business needed Auto Home Secondary Home Rental Property Recreational Vehicle (Boat, Motorcycle, ATV, etc) Umbrella Other Select AllOther Line of Business Auto Underwriting InformationCurrent Auto Carrier Current Agency/Carrier How Long Auto Expiration Date MM slash DD slash YYYY Current Auto BI LimitState Minimum30/6050/100100/300250/500300CSL500CSLCurrent Auto PD Limit10,00050,000100,000250,000500,000Household Drivers (+/- to add/remove)First NameLast NameDOBDL#Good StudentLast Citation(s) Add RemoveGood Student = Ages 16–25 with a GPA of 3.0 or higher. Household Vehicles (+/- to add/remove)YearMakeModelVINDriverUse, Mileage 1-way & Annual Add Remove Home Underwriting InformationCurrent address less than 3 years Yes No Own, Rent or BuyingOwnRentBuyingPrior Address Street Address Address Line 2 City State ZIP Policy TypeHomeownerRentersCondoTownhouseLandlord ProtectorMobile HomeUnits in BuildingHome TypeSingle Story1.5 Story2 StorySplit LevelBi-Level/Raised RanchTownhome (end)Townhome (mid)OtherCurrent Home Carrier Current Carrier How Long Current Home CoveragesCov A DwellingCov B Separate StructuresCov C Personal PropertyLiabDeductibleWind Hail Ded Add RemoveHome UW InfoYear BuiltSq FtRoof ReplaceFurnace ReplaceUpdates? Add RemoveSQ FT above groundBasement? Yes No Basement SQ FTBasement % FinishedGarage TypeAttached 1 CarAttached 2 CarAttached 3 CarBult-in 1 CarBult-in 2 CarBult-in 3 CarCarportDetached# of Bathrooms12345678910# of Fireplaces12345678910Roof TypeAsphalt/ShingleWood ShakeConcrete/CementOtherExterior Walls % of EachBrick VeneerAluminum/Vinyl SidingStucco on FrameStone VeneerWood SidingOther Add RemoveType of Electrical Type of Plumbing Type of HVAC Alarm System Yes No Additional Features Add Value to the Property Deck Hot Tub Pool Central Vac Patio Cover Other Home Add'l Earthquake Coverage Flood Coverage Sewer & Drain Coverage Yes No Buried Utilities Yes No Other Home UW Info Misc UW Info Other Insurance neededFirst Named Insured First Last 1st Named - EducationHigh SchoolAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOther1st Named - Employment Second Named Insured First Last 2nd Named - EducationHigh SchoolAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOther2nd Named - Employment Landlord TypeNoShort Term UseLong Term RentalCommercialUmbrella $1,000,000 $2000,000 $3,000,000 $4,000,000 $5,000,000 Other Lines Life RV Motorcycle Boat Powersports Do you have a business insurance you'd like us to talk about at another time? Yes No Misc UW Info for other lines of business Agent AttributionDate Info Collected MM slash DD slash YYYY Agent Filling Out Form First Last Agent Email
