Ron Jackson Ins – PL Renewal Questionnaire (1) Step 1 of 11 9% FacebookThis field is for validation purposes and should be left unchanged.Name(Required) First Last Email(Required) Phone(Required)Are you driving for a rideshare or delivery company?(Required) Yes No If yes what company?Have you started using your vehicle for business?(Required) Yes No (Roofing, real estate, advertisement, etc.)What Business?Please check all life events that have occurred in the last 12 months.(Required) Address Change Birth of a child Career Change Driver Added Driver Removed Home renovations/improvments Marital Status Purchased ATV/Motorcycle/Slingshot Purchased Boat Purchased Home/Rental Property/Second Home Started A Business Vehicle Bought Vehicle Sold Other Change No Changes Date You Moved(Required) MM slash DD slash YYYY Updated Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Congrats on the new career! What is your new job title & employer?(Required) Driver Added To Policy First Last BirthdayRelationship to YouSpouseChildParentOtherDL #Driver Removed From Policy First Last What is your current marital status? Married Divorced Widowed Spouse Name What new toy(s) did you purchase? ATV Boat Golf Cart Motorcycle Slingshot List make, model and estimated purchase price for each new toy.YearMakeModel Add RemoveClick the + to add more rows. What type of property did you purchase? Primary Home Rental Home/Investment Property Second Home/Vacation Home Date Purchased MM slash DD slash YYYY New Property Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the Property currently insured? With who? What is the name of your business?What is the industry of your new business?Is your business currently insured? Yes No Date Purchased MM slash DD slash YYYY Year/Make/Model of purchased vehicle(s)YearMakeModel Add RemoveClick the + to add rows for additional vehicles.Date Sold MM slash DD slash YYYY Year/Make/Model of sold vehicle(s)YearMakeModel Add RemoveClick the + to add rows for additional vehicles. Please list the renovations and an approximate cost of each. Add RemoveYou can use the + button on the right side to add additional rows. Do you have life insurance independent of your employment?(Required) Yes No Not Sure Please select all property that you own even if it is not insured with our agency.(Required) ATV Auto Boat/Yacht Business Classic Car Condo Golf Cart Home Motorcycle Rental Property RV Slingshot Snowmobile Vacation Property None It is important to know if you own any of the items above because coverages can overlap or leave gaps and you need to be covered correctly.Are there any additional changes that we should know about prior to your insurance renewal?Signature(Required)
