Centurion Insurance Group

Personal Insurance Products

Personal Insurance Survey

This form is for use by Centurion clients

Avoid uninsured losses by keeping your insurance coverage up-to-date.

Help us to keep you from having an uninsured loss. Policy terms and State Insurance Laws change frequently. By using current information you provide on this form, we can advise you of “gaps” in your coverage. Additional credits may also be available.

	In the past year, have you. . . Felt inflation increased the replacement cost of your home? Remodeled, added to, or finished a basement "rec" room? Built or added to unattached structure (garage, barn, etc.)? Refurnished your home, or purchased additional or new appliances? Purchased or acquired jewelry; furs; photographic, sports or golf equipment; stamp or other collections; fine arts; silver service or flatware; other personal property of unique or antique value? Remortgaged, arranged a second mortgage or home equity loan, or paid off a mortgage? Increased or decreased the number of apartments in your home? Purchased or sold property-houses, land, mobile homes? Added or deleted an office, professional school, or studio occupancy in your home? Installed / Removed (circle one) smoke, fire, or burglar alarms, or sprinklers? Employed or released resident employees who work more than 20 hours per week? Taken in roomers or boarders? Increased the size of your family? Installed a swimming pool? Added to, replaced, or decreased the number of owned or leased motor vehicles, or had vehicle furnished to you for your regular use? Had residents of your household newly licensed to operate motor vehicles? Added or deleted a lienholder to vehicle(s)? Become a licensed pilot Acquired, replaced or eliminated watercraft or recreational vehicles? Had any family member elected to serve on any Board of Directors (civic or corporate)? Had a change in marital status? Started Smoking? Stopped Smoking? Become a member of the Hanover Food Co-Op (Hanover, NH)? If yes, member # Installed a wood stove? Acquired personal computer equipment or home entertainment equipment? Value $ Started or now operate a daycare in your home? # of children Would you like to know more about. . . Personal Catastrophe (Umbrella) Liability Insurance Mortgage Life Insurance Disability Income Insurance Estate Planning Your current life insurance policy Credits for higher deductibles Coverage for custom-installed automobile stereos, C.B.s or cellular telephones Self-employed professional liability and malpractice coverage Earthquake coverage Flood coverage Replacement cost on contents
	*Your Name:
	Gender:	Female Male
	*E-Mail Address:
	Other: comments, questions and concerns:
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