Annual Insurance Review

First Name

Last Name

Phone

Email Address

What is the best way to contact you? Email Phone

We want to be sure we are meeting all of your insurance needs and providing you with the peace of mind you deserve.

Upon completion of this form, your agent will contact you to:

Evaluate your insurance policies and verify that your most valuable assets are adequately protected.
Answer your questions you have about your coverages and identify any discounts you may be eligible for

Auto Insurance

Do any of your licensed children qualify for the good student discount (grade B or above)? Yes No N/A Not Sure

Have you purchased or sold a vehicle lately that needs to be added or removed from your policy? Yes No N/A Not Sure

Do we insure all of the vehicles you own? Yes No N/A Not Sure

Do you have any children away at school? Yes No N/A Not Sure

Do you have another car to use if your car needs to be repaired because of a claim? Yes No N/A Not Sure

Have you added any equipment other than the manufactured-installed items to your vehicle? Yes No N/A Not Sure

Have you recently purchased any of the following miscellaneous vehicles? (please check all that apply) Motorcycle ATV Antique/Classic Car Golf Cart Motor Home Trailer Snowmobile Camper

Home Insurance

Does your home have any new additions, remodeling projects, or updates? (i.e. new roofing or siding) Yes No N/A Not Sure

Are there valuables in your basement that need protection from water damage? Yes No N/A Not Sure

Is there any type of business being conducted from your home (i.e. Mary Kay, Avon, etc.)? Yes No N/A Not Sure

Have you recently purchased any of the following? (please check all that apply) Computers Jewelry Firearms Condo Collectibles Boat Fine Art Rental Property Second Home (vacation property) Additional structures on property

Other

Are you interested in coverage that protects you against identity theft? Yes No

Are you interested in an umbrella policy that protects your family and assets against large personal liability lawsuits? Yes No

Are you interested in reviewing life insurance policies? (You may qualify for a life discount) Yes No

Are you interested in an annuity saving plan (i.e. IRA, Roth)? Yes No N/A Not Sure

Are you interested in changing your deductible to possibly save money? Yes No N/A Not Sure

Are you interested in a hassle-free electronic payment option for your insurance bill? Yes No N/A Not Sure

Feedback

How satisfied are you with your insurance experience with Prairieland Insurance Group, LLC? Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied

Please list any additional comments or questions below

Thank you for taking the time to complete your annual insurance check-up!

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Our Locations Champaign Office: 217-352-9000
Rantoul Office: 217-892-9200
Newman Office: 217-837-2713