New Client Information Form - American Family Insurance

NEW CLIENT INFORMATION(For office use only)Thank you for visiting our agency today. Please take a moment to fill out this short form so that we may betterserve your insurance needs.NAMEDATEADDRESSCITY STATE ZIPHOME PHONEE-MAIL ADDRESSWORK PHONECELLULAR PHONEHow do you prefer to be contacted by our agency? ❑ Home Phone ❑ Work Phone❑ E-Mail ❑ Cellular PhoneBy signing, I am giving American Family permission to call me: ______________________________________(Signature)How did you hear about our agency? __________________________________________________________What type of insurance coverage are you visiting with us about today? _______________________________Household MembersName_________________________________Birth Date______________________Relationship_____________________________________________________________ ______________________ _____________________________________________________________ ______________________ _____________________________________________________________ ______________________ ____________________________Property Insurance:Do you? ❑ Own ❑ RentWhat company currently insures your property? __________________________________________________Expiration date (Circle One):Jan Feb Mar Apr May June July Aug Sept Oct Nov DecHave you made any changes or improvements to your home since purchasing this policy? ❑ Yes ❑ NoIf yes, what type? __________________________________________________________________________Do you have any jewelry, guns, computers, collectibles, etc. that may need specific coverage considerations?❑ Yes ❑ No ❑ Don’t knowIf yes, what type? __________________________________________________________________________Do you own a business? ❑ Yes ❑ NoInformation about your insurance coverageIf yes, what type? __________________________________________________________________________Do you provide childcare in your home? ❑ Yes ❑ No If yes, # of children ____________________American Family Mutual Insurance Company and its SubsidiariesAmerican Family Insurance Company ADO-22117 Ed. 1/10Home Office - Madison, WI 53783 © 2010

Do you currently own a Personal Liability Umbrella policy? ❑ Yes ❑ NoDo you own any rental or vacation property? ❑ Yes ❑ NoIf yes, what type? __________________________________________________________________________Do you have any animals? ❑ Yes ❑ No If yes, what type?________________________________Have you had any homeowner/property claims in the last 5 years? ❑ Yes ❑ NoIf yes, please describe: _____________________________________________________________________Are you interested in identity-theft services? ❑ Yes ❑ NoAuto Insurance:What company currently insures your vehicles? ___________________________________________________Expiration date (Circlene):Jan Feb Mar Apr May June July Aug Sept Oct Nov DecWhat types of vehicles do you own? Is this vehicle Is this a leased(Year/Make/Model) financed? vehicle?Vehicle #1Vehicle #2Vehicle #3Vehicle #4Do you own any boats, recreational vehicles or motorcycles? ❑ Yes ❑ NoIf yes, what type? ___________________________________________________________________________Are you interested in Emergency Road Service? ❑ Yes ❑ NoLife and Health Insurance:Do you have life insurance for any of the following? ❑ Yourself ❑ Spouse ❑ ChildrenIf yes, what type of life insurance do you currently have?POLICYHOLDER INSURANCE TYPE OF AMOUNT OF REASON FOR PURCHASENAME COMPANY POLICY BENEFIT (Mortgage/Income Replacement/DebtClearance/Other)Do you?❑ Have health insurance❑ Purchase it independentlyDo you currently own any annuities? ❑ Yes ❑ NoDo you own an IRA, 401K, or company sponsored retirement savings program? ❑ Yes ❑ NoWhen was the last time your insurance program was reviewed?❑ Less than 1 year ago ❑ 1 – 2 years ago ❑ 2 – 5 years ago ❑ NeverWe appreciate the opportunity to serve your insurance needs!American Family Mutual Insurance Company and its SubsidiariesAmerican Family Insurance Company ADO-22117 Ed. 1/10Home Office - Madison, WI 53783 © 2010