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Home
About Us
The KIS Team
Services
Personal Insurance Options
Business Insurance Options
Financial Planning/Estate Planning
FAQs
Client Resources
Account Management/Claims
Life Insurance Questionnaire
Personal Insurance Questionnaire
Business Insurance Questionnaire
Renewal Questionnaire
Contact Us
Thoughtful Protection for Exceptional Assets
New Personal Insurance Questionnaire
kisadmin
2026-04-14T12:19:40-06:00
Personal Insurance Questionnaire
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Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Phone
*
Address
*
Email
*
Who do we have to thank for referring you to our office?
Occupation/Degree
*
Driver 1: Name
*
Driver 1: Birthdate
*
Driver 1: Drivers License Number
*
Driver 2: Name
Driver 2: Birthdate
Driver 2: Drivers License Number
Driver 3: Name
Driver 3: Birthdate
Driver 3: Drivers License Number
Household Accidents/Tickets (last 3 years)
*
Vehicle VIN#
*
1)
Vehicle VIN#
2)
Vehicle VIN#
3)
Lien Holder(s)
Current Insurance Carrier
*
Current Liability Limits
*
($100,000/$300,000, $250,000/$500,000, $500,000 Combined Single Limit, etc.)
Length of Continuous Coverage with Carrier
*
Do you have a trailer/camper?
*
YES
NO
Trailers/Campers
Year: Make: Model: Value:
Trailer/Camper VIN#
Contents Coverage
YES
NO
Where is trailer/camper stored?
Do you have motorcycles/dirt bikes?
*
YES
NO
Motorcycle/Dirt bike
Year: Make: Model: Value: CC's
Do you own any antique or collector vehicles over 19 years old?
*
YES
NO
Vehicle info
Year/make/model
Vehicle value
Do you have any boats or personal watercrafts?
*
YES
NO
Boat/watercraft info:
Do you have any ATV's/Snowmobiles/Golf Carts?
*
YES
NO
Home/Umbrella
Is your home titled in the name of a trust?
*
YES
NO
Please provide the name of the trust:
Do you have any dogs?
*
YES
NO
What breed?
Do you have a trampoline?
*
YES
NO
Is there unrepaired damage to your home?
*
YES
NO
What year was your home built?
*
Square footage (not including basement)
*
Exterior type (brick/frame, etc.)
*
Style (ranch, 2-story, tri-level, condo, duplex)
*
Basement
*
YES
NO
Percentage finished
Selected Value:
0
Walkout?
*
YES
NO
Bathrooms (full, 3/4, half)
*
Bathrooms are
*
Standard
Custom
Roof type
Asphalt
Tile
Wood shake
Metal
T-lock
Double layered
Steel
Slate
Other
Age of roof (new roofs require documentation)
*
Impact Resistant Shingle
*
YES
NO
Garage type (size, attached, detached, or built-in)
*
Kitchen grade
*
Standard
Above Average
Custom
Luxury
Increased limits on Personal Property (jewelry, art, silverware, firearms)
*
Other features (select all that apply)
Wet bar
Fireplace(s)
Hot tub
Swimming Pool
Solar Panels
AC
Deck
Skylight(s)
Security
Gated community
Burglar alarm
Fire alarm
Fire sprinkler system
Water leak detection system
Last claim on your home (year and brief description of loss)
Do you have a mortgage on your home?
*
YES
NO
Mortgage information (name, type, and loan #)
Premium escrowed
YES
NO
Do you own vacant land?
*
YES
NO
Number of acres
Do you own rental properties?
*
YES
NO
Rental address(es)
Have there been any significant life changes since you last reviewed your estate plan?
*
YES
NO
I don't have an estate plan and would like help in this area
Please explain these life changes:
Do you currently have Umbrella coverage?
*
YES
NO
UNSURE
Do you have life insurance?
*
YES
NO
Would you like to discuss life insurance with us?
*
YES
NO
Any other information you would like us to know when quoting your policies?
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