Insurance Review Questionnaire

Name(Required)

First Last

Email(Required)

Phone(Required)

I have recently married, divorced, had a baby, bought a new pet or other major life event.(Required)

Yes

I own property, land, or structures not presently insured with JD Fulwiler.(Required)

Yes

I have recently renovated or remodeled my home (including increasing square footage, replacing the roof, upgrading heat, plumbing or electric).(Required)

Yes

I employ a worker in my home for housework, yard work, childcare, etc.(Required)

Yes

I am interested in additional or increased limits coverage for jewelry, guns, furs, antiques, fine arts, collectibles, or silverware.(Required)

Yes

I share my home with a non-related person, boarder, foster child, or am a legal representative for a household member.(Required)

Yes

I have placed my home in a trust or deeded my home to someone else.(Required)

Yes

I have moved/stored some of my contents to an offsite storage facility.(Required)

Yes

I conduct business in my home (including day care, home office, internet auctions, home shows/parties, etc.).(Required)

Yes

I use my vehicle for business purposes either for myself or my employer.(Required)

Yes

I have had a home security system installed in the past year.(Required)

Yes

I own a travel trailer or other recreational vehicle.(Required)

Yes

I have a non-owned vehicle furnished for my regular use (i.e., company car).(Required)

Yes

I am currently insuring a vehicle that is not registered and titled in my or my spouse’s name or my vehicle is not registered in the state where it is garaged.(Required)

Yes

There are other licensed, or instruction permit, members of my household not listed on my policy.(Required)

Yes

I am using my vehicle for a ride sharing service, i.e.: Uber, Sidecar, Wingz, Lyft, or a food delivery company, i.e.: Door Dash, Grub Hub, Uber Eats. (Traditional carpooling arrangements are not considered Transportation Networking Companies).(Required)

Yes

I am currently renting all or part of my residence - regularly, or on a short-term basis, such as Airbnb.(Required)

Yes

I have significantly modified my vehicle (ex: stereo system/made handicap accessible/paint/graphics).(Required)

Yes

I own an e-bike, motorcycle, boat or recreational vehicle which is currently uninsured.(Required)

Yes

I have a child who has a B average/3.0 GPA not currently receiving a discount on my policy.(Required)

Yes

I have a child who is in college over 100 miles from my home.(Required)

Yes

I have retired or have changed my commute distance within the last year.(Required)

Yes

I have a vehicle insured on my policy that is not kept/stored at my house.(Required)

Yes

I am planning or have already booked an international trip.(Required)

Yes

I own a pet.(Required)

Yes (please list breed below)

Breed Information

I am interested in Pet Insurance

Yes

OTHER INSURANCE: Would you like us to review any other insurance not presently insured with JD Fulwiler? (Could include: Vision, Dental, Flood, Life, Health, Trip Cancellation and Umbrella, Rental Property, Flood, Earthquake).(Required)

Yes

Additional Comments, Information, Questions or Concerns?

Please contact me to review(Required)

Yes, please email me.

Yes, please call me.

No, I do not need to be contacted to review.