Name(Required)

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A thorough review includes completing each of the sections listed below. If anything does not apply to you, please uncheck the box(es).

Home

Secondary Home

Valuable Articles

Automobile

Liability

Home Review

Let's start with your home.

Did you install an Alarm System in the last 12 months?

Yes

Which components are included in your alarm system?

Check all that apply.

Centrally monitored fire alarm

Centrally monitored burglar alarm

Fire / Smoke

Burglar / Motion

Low Temperature

Water Leak Detection / Automatic shut-off valve

Cellular Backup

Gas Leak Detection

Other

Describe Other component of alarm system

Is your home owned in a Trust, LLC, or other legal entity?

Yes

Name of Trust, LLC, or other legal entity

Any updates, renovations, additions planned or recently completed?

Yes

Please tell us about your updates

Have you updated any of these?

Electrical

Plumbing

Heating

Windows / Doors

Roof

No Updates

Does your home have solar panels?

Yes

How is the solar power being used?

Check all that apply.

Home Power Generation

Pool Heating

Other

Number of solar panels

Value of solar panels

Where are the solar panels located?

Check all that apply.

Roof of the Main Dwelling

Roof of a Secondary Structure

Ground Mounted

Other

Do you own or lease the solar panels?

Own

Lease

Are you responsible for insuring the panels?

Yes

Has the occupancy status of your home changed?

Yes

How has your home occupancy changed?

Renting long-term

Renting short-term (by day, week, or month)

Unoccupied for greater than 30 days

Unoccupied and for sale

Other

Describe Other occupancy change

Does your home have an underground oil tank?

Yes

Would you like to discuss getting Flood Insurance or increasing your flood insurance limits?

Yes

Would you like to get, or increase, fungi or mold coverage?

Yes

Would you like to get, or increase, coverage for personal Cyber protection?

Yes

Unsure

Any business conducted at your home?

Yes

Please tell us about your home business

What risk management strategies do you use at this home?

Check all that apply.

Permanently installed back-up generator

Water flow monitor and automatic water shut-off valve

Gated home with perimeter fencing

Lightning protection system

24-hour guarded and gated community

24-hour professionally monitored video surveillance

Full-time live-in caretaker

Indoor sprinkler system

Seismic shut-off valve

Hurricane rated shutters or window protection

Other

None

What Other risk management strategies do you use?

Is there anything else you would like to discuss regarding your home insurance?

Secondary Home Review

Let's review another home.

Please provide a name for this home

Example: Florida Home

Did you install an Alarm System in this home in the last 12 months?

Yes

Which components are included in this alarm system?

Check all that apply.

Centrally monitored fire alarm

Centrally monitored burglar alarm

Fire / Smoke

Burglar / Motion

Low Temperature

Water Leak Detection / Automatic shut-off valve

Cellular Backup

Gas Leak Detection

Other

Describe Other component of this alarm system

Is this home owned in a Trust, LLC, or other legal entity?

Yes

Full legal name of Trust, LLC, or legal entity

Any updates, renovation, or additions planned or completed for this home?

Yes

Please tell us about your updates to this home

Have you updated any of these on this home?

Electrical

Plumbing

Heating

Windows / Doors

Roof

No Updates

Does this home have solar panels?

Yes

How is solar power used?

Check all that apply.

Home Power Generation

Pool Heating

Other

Number of Panels

Value of Panels

Where are solar panels located?

Check all that apply.

Roof of the Main Dwelling

Roof of a Secondary Structure

Ground Mounted

Other

Own or lease the solar panels?

Own

Lease

Responsible for insuring the panels?

Yes

Has the occupancy status of this home changed?

Yes

How has this home occupancy changed?

Renting long-term

Renting short-term (by day, week, or month)

Unoccupied for greater than 30 days

Unoccupied and for sale

Other

Describe occupancy change

Does this home have an underground oil tank?

Yes

Would you like to discuss getting Flood Insurance or increasing your flood insurance?

Yes

Would you like to get, or increase, fungi or mold coverage?

Yes

Would you like to get, or increase, coverage for personal Cyber protection?

Yes

Unsure

Any business conducted at this home?

Yes

Please tell us about the home business

What risk management strategies do you use at this home?

Check all that apply.

Permanently installed back-up generator

Water flow monitor and automatic water shut-off valve

Gated home with perimeter fencing

Lightning protection system

24-hour guarded and gated community

24-hour professionally monitored video surveillance

Full-time live-in caretaker

Indoor sprinkler system

Seismic shut-off valve

Hurricane rated shutters or window protection

Other

None

What Other risk management strategies do you use?

Is there anything else you would like to discuss regarding this home insurance?

Valuable Articles Review

Let's review your valuable articles coverage.

Any significant acquisitions in the last 12 months we should know about such as

Jewelry

Fine Art

Silverware

Wine

Antiques

Firearms

Collectibles

Other

None

Please provide a brief description of item(s) purchased or aquired

Click the plus icon (+) to the right to add multiple items.

Item Description

Value ($)

Do you have an appraisal for any of your valuables?

Yes

Upload Appraisal(s)

Drop files here or

Max. file size: 1 MB.

Are any valuable items stored in a bank vault?

Yes

What risk management strategies do you use to protect your valuables?

Permanently installed safe at home

Wireless tracking sensors

Alarm system

Other

None

Please briefly describe your protection strategies for your valuables

Are any valuables owned in a Trust or LLC?

Yes

Please describe the items owned in the Trust or LLC and provide the name of the entity.

Anything else you would like to discuss regarding your valuables?

Example: Loaning to a museum, or repairs being done.

Automobile Review

Let's review your automobile coverage.

Have you purchased any vehicles in the past 12 months?

Yes

Vehicle 1

1. Year

1. Make

1. Model

1. VIN

2. Add Vehicle

Add Another Vehicle

Vehicle 2

2. Year

2. Make

2. Model

2. VIN

3. Add Vehicle

Add Another Vehicle

Vehicle 3

3. Year

3. Make

3. Model

3. VIN

4. Add Vehicle

Add Another Vehicle

Vehicle 4

4. Year

4. Make

4. Model

4. VIN

5. Add Vehicle

Add Another Vehicle

Vehicle 5

5. Year

5. Make

5. Model

5. VIN

Have you sold or turned in any vehicles in the past 12 months?

Yes

Please enter Year, Make, Model of each vehicle(s) you sold or turned in

Any new drivers to be added to your policy?

Yes

Driver 1

1. Driver Name

First Last

1. Date of Birth

Month

Day

Year

1. Drivers License Number

1. Drivers License State

2. Add Driver

Add Another Driver

Driver 2

2. Driver Name

First Last

2. Date of Birth

Month

Day

Year

2. Drivers License Number

2. Drivers License State

3. Add Driver

Add Another Driver

Driver 3

3. Driver Name

First Last

3. Date of Birth

Month

Day

Year

3. Drivers License Number

3. Drivers License State

Any drivers away at school without a car?

Yes

Soon

Please enter name of student and location of school

Click the plus icon (+) to the right to add multiple students.

Student Name

School Name

School City & State

Have you paid off any car loans?

Yes

Soon

Which vehicles did you pay off?

Include Year, Make, Model of each vehicle.

Any vehicles used for business purposes?

Including ride sharing services such as Uber and Lyft.

Yes

Please briefly describe the car and the business

Click the plus icon (+) to the right to add multiple vehicles.

Vehicle

Business Description

Anything else you would like to discuss regarding automobile insurance?

Liability Review

Let's review your liability exposures.

What is your approximate net worth?

Up to $1 Million

$1 Million - $5 Million

$5 Million - $10 Million

Above $10 Million

Please contact me

Tell us about your liability risks

Select all that apply.

Own a pool or have a pond on my property

Youthful driver

Sit on a not-for-profit board

Domestic employee

Own foreign property

Own a pet who could cause harm to a human

In-home business

Own a motorcycle

Own a boat

Own a recreational vehicle

Other

None

Please describe Other liability risk(s)

Is there anything else you would like to discuss regarding your liability protection?

Wrapping Up

Would you like to discuss any other topics?

Building a house

Buying or Selling property

Having a child

Change of marital status

Death of a spouse

Child going to college

Property held for rental

Starting a business

Planning a big trip

Other

None

What Other topic would you like to discuss?

Your Agent

Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

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By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.

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Nelson Insurance Agency

2200 W 49th St, Ste 100

Sioux Falls, South Dakota 57105

Phone: 605-275-9700
Secondary phone: 605-453-5583
Email: processing@nelsoninsurancesf.com

Monday	8:30 AM - 6:00 PM
Tuesday	8:30 AM - 6:00 PM
Wednesday	8:30 AM - 6:00 PM
Thursday	8:30 AM - 6:00 PM
Friday	8:30 AM - 6:00 PM

Account Review – Personal Lines

Home Review

Secondary Home Review

Valuable Articles Review

Automobile Review

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Driver 1

Driver 2

Driver 3

Liability Review

Wrapping Up

Nelson Insurance Agency

Nelson Insurance Agency

Get a Quote

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Account Review – Personal Lines

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Vehicle 1

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