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Home > Automobile or Boat Insurance Review Questionnaire Form

Automobile or Boat Insurance Review Questionnaire Form

NOTE: Please do not click the back button on your browser as your information will be deleted, and will have to be re-entered.
Do NOT HIT ENTER at ANY TIME or you will close this form. You MUST TAB or CLICK on each Yes or No answer. To type answers, click inside EACH BOX and fill in the information. Once you have completed the form, click submit.
Please Enter Your Policy Number As Listed On The Letter You Have Received:*

*Note: You CANNOT enter multiple policy numbers. Each policy/letter must have its own questionnaire completed*
To whom is/are the vehicle(s) titled/resgistered? Please advise:
Are all owned vehicles listed on the policy?
- Yes
- No
Is the garaging address listed on your policy correct? If not, please list the correct address below:
Do you have a vehicle, not owned by you, furnished for your regular use?
- Yes
- No
If your vehicle is a pick up truck does it have a cap, or camper shell on the back, or other non – factory installed equipment?
- Yes
- No
Are there any non-household members who regularly use your vehicle?
- Yes
- No
If your vehicle is financed is the leinholder properly listed on the policy?
- Yes
- No
Is your vehicle leased?
- Yes
- No
Which vehicle(s)?
Do you have a stereo or other electronic device not factory installed?
- Yes
- No
Is your vehicle used in your business?
- Yes
- No
Do you haven any signs or advertisements on your vehicle(s)?
- Yes
- No
Do you drive your vehicle to and from work?
- Yes
- No
If yes, per vehicle, how many miles are traveled each way, and how many days per week do you commute?
Please indicate below the number of miles driven annually for each vehicle:
Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Would you be interested in a quote for Homeowner's Insurance?
- Yes
- No
Would you be interested in a quote for Umbrella Liability?
- Yes
- No
Would you be interested in a quotation for Life, Disability, or Health insurance?
- Yes
- No
Do you work in any ride sharing capacity with any company such as Uber or Lyft?
- Yes
- No
Please list all household members below. Please include name, date of birth, and drivers license number.
Name Date of Birth Driver's License #
Please indicate below any children in the household that are approaching driving age:
Please indicate below any changes that you would like to make to any of your coverage:
Bodily Injury Liability Limits:
Property Damage Liability Limits:
Personal Injury Protection Limits:
Would you be interested in Extended PIP?
- Yes
- No
Would you be interested in Additional PIP?
- Yes
- No
Medical Payments Limits:
Uninsured/Underinsured Motorist Limits:
Would you be interested in Stacked Uninsured Motorist Coverage?
- Yes
- No
Collision Deductible:
Comprehensive Deductible:
Rental Reimbursement Limits:
Towing & Labor Limits:
Would you be interested in loan/lease Gap Coverage?
- Yes
- No
Would you be interested in New Car Replacement Coverage?
- Yes
- No
If you are a SafeCo, Progressive, Travelers or Nationwide policy holder, would you be interested in their coverage enhancement endorsement (gives a package of additional coverage)?
- Yes
- No
If you are a SafeCo, Progressive, Travelers or Nationwide policy holder, would you be interested in their usage based insurance program (could potentially provide discounts)?
- Yes
- No
Thank you for taking the time to complete this questionnaire.
Insured’s Signature
Date
Home Phone Number
Work Phone Number
Cell Phone Number
Email Address:
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The Turner Insurance Advisor Group

2121 NE Coachman Road
Clearwater, Florida 33765

Phone: (727) 442-0012

Fax: (727) 446-9147

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Sat-Sun: Closed

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The Turner Insurance Advisor Group specializes in Auto & Home Insurance, Business Insurance, Homeowners Association (HOA) & Community Association Insurance for all of Florida, including Clearwater, Tampa, St. Petersburg, New Port Richey, Spring Hill, Palm Harbor, Oldsmar, Tarpon Springs, Land O Lakes, and Dunedin.

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