Umbrella Insurance Survey

Insured Information

What is your full name?

What is your Mailing Address?

City (mailing)

State (mailing)

Zip (mailing)

Country (mailing)

Primary Residence Address same as Mailing Address?

What is your Primary Address?

City (primary)

State (primary)

Zip (primary)

Country (primary)

What is your home phone number?

What is your email address?*

Driver/Automobile Information

Current Carrier/Prior Insurance

Length with Current Carrier

When do you want your policy to be effective?

Driver #1 Name

Gender

Male Female

Marital Status

Date of Birth

Driver License #

US State Issuing Driver's License

Any Violations / Accidents? (Last 3 Years)

Driver #2 Name

Gender

Male Female

Marital Status

Date of Birth

Driver License #

US State Issuing Driver's License

Any Violations / Accidents? (Last 3 Years)

Add another driver?

Driver #3 Name

Gender

Male Female

Marital Status

Date of Birth

Driver License #

US State Issuing Driver's License

Any Violations / Accidents? (Last 3 Years)

Add another driver?

Driver #4 Name

Gender

Male Female

Marital Status

Date of Birth

Driver License #

US State Issuing Driver's License

Any Violations / Accidents? (Last 3 Years)

Vehicle Information

Vehicle 1 Year

Vehicle 1 Make

Vehicle 1 Model

Vehicle 2 Year

Vehicle 2 Make

Vehicle 2 Model

Add another vehicle?

Vehicle 3 Year

Vehicle 3 Make

Vehicle 3 Model

Add another vehicle?

Vehicle 4 Year

Vehicle 43 Make

Vehicle 43 Model

Residence Information

Number of Residents

Insurance company that current insures the property

Limits

Location Address

What is the occupancy of this property?

Primary Residence Seasonal Residence Rental Vacant

Which months during the year do you occupy the property?

If you rent the property, which months during the year do you rent the property?

If you rent the property, what is the minimum amount of time (weeks/months/annually) each renter will occupy the property?

Is a business operated at this property?

Yes No

If yes, provide details.

Do you have any pets or other animals living at this property?

Yes No

If yes, list type and breed.

Have you reported any losses in the last 3 years for this property?

Residence #2 Information

Number of Residents

Insurance company that current insures the property

Limits

Location Address

What is the occupancy of this property?

Primary Residence Seasonal Residence Rental Vacant

Which months during the year do you occupy the property?

If you rent the property, which months during the year do you rent the property?

If you rent the property, what is the minimum amount of time (weeks/months/annually) each renter will occupy the property?

Is a business operated at this property?

Yes No

If yes, provide details.

Do you have any pets or other animals living at this property?

Yes No

If yes, list type and breed.

Have you reported any losses in the last 3 years for this property?

Other Exposure Information

Do you own any tracts of undeveloped land?

Yes No

If yes, how much?

Who currently insures the undeveloped land?

If yes to above provide the current limits

Do you own any watercraft?

Yes No

Watercraft #1

Year

Make

Model

If yes to above provide the Length

Horsepower

Maximum Speed

If yes, who currently insures the watercraft?

If yes, provide the current limits

Watercraft #2

Year

Make

Model

If yes to above provide the Length

Horsepower

Maximum Speed

If yes, who currently insures the watercraft?

If yes, provide the current limits

Do you own any recreational vehicles?

Yes No

If yes, who currently insures the RV?

If yes, provide the current limits

Do you own any off road vehicles?

Yes No

If yes, provide the name of the current carrier:

If yes, provide the current limits

Are you a member of a Board of Directors?

Yes No

If yes, provide the name of the current carrier:

If yes, provide the current limits

Coverage Information

Limit

Excess Uninsured Motorist

Optional Limit

Any additional comments?

By checking this button, you certify that all information provided is accurate.

Are you currently a client of IRMS?

Yes No

If yes, who is your agent:

Dawn Zettler Inge Hutson Joann Whitney None

If no, have you spoken to any of the following agents?

Dawn Zettler Inge Hutson Joann Whitney None

Naples: 8950 Fontana Del Sol Way, Suite 200 | Naples, Florida 34109
Phone: 239-649-1444 | Fax: 239-649-7933
Fort Myers: 9530 Marketplace Road, Suite 205 | Fort Myers, Florida 33912
Phone: 239-275-0151 | Fax: 239-275-0272

Web Design & Hosting by Golden Technologies

Trusted Choice® Pledge of Performance

Trusted Choice® agencies are insurance and financial services firms whose access to multiple companies and commitment to quality service enable us to offer our clients competitive pricing, a broad choice of products and unparalleled advocacy.

As a Trusted Choice® agency, we are dedicated to you and are committed to treating you as a person, not a policy. This commitment means we shall:

Work with you to identify the insurance and financial services that are right for you, your family or your business and use our access to multiple companies to deliver those products.
Guide you through the claims process for a prompt and fair resolution of your claim.
Help you solve problems related to your coverage or account.
Explain the coverages and options available to you through our agency, at your request.
Return your phone calls and e-mails promptly and respond to your requests in a timely manner.
Provide 24/7 services for our customers, offering any or all of the following: emergency phone numbers, Internet account access, e-mail and call center services.
Use our experience and multiple company relationships to customize your coverage as needed.
Commit our staff to continuing education so they may be more knowledgeable in serving you.
Treat you with respect and courtesy.
Conduct our business in an ethical manner.

We pledge this to you, our clients and ask that you let us know if we fail to meet our commitment, so we may take corrective action.

Simply selling insurance is not enough!®

Umbrella Insurance Survey

Insured Information

Driver/Automobile Information

Vehicle Information

Residence Information

Residence #2 Information

Other Exposure Information

Watercraft #1

Watercraft #2

Coverage Information

Trusted Choice® Pledge of Performance

Simply selling insurance is not enough!^®