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Products
Industry Expertise
About Us
Client Corner
- Client Resources
- Client CSR 24 Portal
Blog
Join Our Team
Contact

Insurance Review Questionnaire

Insurance Review Questionnaire

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

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

No

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

Yes

No

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

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

I own a pet.(Required)

Yes (please list breed below)

No

Breed Information

I am interested in Pet Insurance

Yes

No

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

No

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.

Individual Insurance Products

AUTO, MOTORCYCLE, & RV (VEHICLES)

EXCESS LIABILITY & UMBRELLA

HEALTH, LIFE, & DISABILITY

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Questions?

800.735.8325

Portland

5727 S Macadam Ave
Portland, OR 97239
Tel: 503.293.8325
Fax: 503.293.5418
800.735.8325
info@jdfulwiler.com

Vancouver

330 E Mill Plain Blvd., Ste 403
Vancouver, WA 98660
Tel: 503.293.8325
Fax: 503.293.5418
800.735.8325
info@jdfulwiler.com

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