Client Profile

Thank you for allowing us to update your household data. This allows us to properly rate for all exposures, while confirming that you are receiving all possible discounts.

Completing this profile by May 4th, 2012 will automatically enter you into a drawing to win a free 42" LCD TV!

Your Information

First Name: *	Last Name: *
Are you an existing, active client of ours? yes no
E-mail Address: *	Phone Number: *
Residence Address:
Mailing Address:
Date of birth:	CA Driver's License Number:
Spouse's First Name:	Spouse's Last Name:
Spouse's date of birth:	Spouse's CA Driver's License Number:

Other Household Members

Please list any other members living in your household
Name:	Date of birth:	CA Driver's License Number:
Name:	Date of birth:	CA Driver's License Number:
Name:	Date of birth:	CA Driver's License Number:

Occupation

Occupation: *	Are you self employed? yes no	Employer or Business Name:
Spouse's Occupation:	Is your spouse self employed? yes no	Spouse's Employer or Business Name:
** Please note that certain occupations qualify for additional discounts that can be applied to your home and auto insurance policies.
Would you be interested in receiving more information about business insurance? yes no

Homeowner

Are you a homeowner? * (If not please skip this section) yes no
Approximate loan balance amount:
Current Interest Rate:	Interest Rate Type: fixed adjustable
Do you have Mortgage Insurance Protection? yes no	Would you like more information? yes no
Do you plan on relocating or selling your home within the next year? yes no
Do you have a home office related to your business? yes no
Do you own any jetskis, quads, dirt bikes, boats, or other recreational vehicles? yes no		If yes, please give details:
Are you concerned about your retirement savings and interested in options that can guarantee a lifetime income stream? yes no

Our Services

Would you like for us to contact you to schedule a review of your insurance needs and answer any question you may have? * yes no
What is the best way for us to reach you?
Please keep in mind that we are a full service agency. Please check any of the following services that you would like more information about: Dental Vision Loss of Income Protection Medical Long Term Care Mortgage Insurance Medi-care Supplement Annuity IRA Workers' Compensation Business Insurance Home Refinance Debt Consolidation

Limit one entry per household and/or business entity. The drawing will be held on May 4th, 2012 at 5pm. You do not need to be present to win. We will contact the winner.