Personal Risk Management Exposure Survey Questionnaire

PRE-INTERVIEW INFORMATION

Named Insured:

Date :

To perform an effective assessment of your exposure to loss, we will need a substantial
amount of information. Therefore, please begin gathering the information indicated below
prior to our interview. This effort on your part should save us a substantial amount of time
during the interview

Background Information

1. List below all persons/parties you could be held responsible for or for whom you have a relationship, including:
  • Spouse
  • Domestic partner
  • Resident relatives
  • Resident nonrelatives
  • Nonresident relatives including college students
  • Trusts
  • Limited liability
Name/Entity Relationship D.O.B. if driver
2. If address for any person/party listed above is different, specify name and address:
Name/Entity Address

Personal Property Exposures

a. Jewelry
b. Fine arts
c. Furs
d. Antiques
e. Silverware/goldware/platinumware
f. Precious metal objects or ornaments
g. Glassware

h. China
i. Stamp collections or philatelic property
j. Coin, currency, bullion
k. Valuable books, documents, papers, photos
l. Manuscripts
m. Trophies, cups or prizes
n. Statuary
o. Photography, video equipment
p. Communications equipment

i. Satellite dish
ii. Radio or television tower
iii. VCR/stereo equipment
iv. Other equipment:

q. Sports equipment

i. Golf carts/equipment
ii. Scuba gear
iii. Firearms and related equipment
iv. Fishing tackle and related equipment
v. Ski gear
vi. Snowmobiles
vii. Other equipment:

r. Computer

i. Hardware
ii. Software
s. Wine collection
t. Model aircraft
u. Tools
v. Musical instruments
w. Other collectibles:

Automobile Exposures


1. List all licensed vehicles, including motorcycles designed for public roads, trailers, campers, motor homes,owned, leased, or furnished for your regular use.


Year Make/Mode Owned (O)Leased (L)Furnished (F) Name of Principal Driver

2. List all unlicensed vehicles, such as mopeds, mini-bikes, all terrain vehicles, dune buggies, golf carts, snowmobiles, and related vehicles.


Year Make/Mode Owned (O)Leased (L)Furnished (F) Name of Principal Driver

3. List all significant accessories to owned or leased vehicles, such as customized items, accessories, toolboxes, and related items.


Description Location Value

4. How many miles do drivers live from their work/school?


Individual Miles from Work/School

Watercraft Exposures


1. List all owned, leased, or furnished (e.g., by an employer or another party) boats, motors, and trailers.


No. Year Make Watercraft Type Owned (O)Leased (L) Furnished (F) Name of Owner(s)
1

2

3

4

5

No. Motor Type Inboard Outboard Inboard/Outboard Jet Drive Sail Row Other H.P. Length Value Safety Features
1
2
3
4
5

2. List all other operators and their years of experience on the appropriate watercraft.


3. List auxiliary equipment by type and value.


Type Location Value

Aircraft Exposures


1. List all owned or leased aircraft, including any aircraft for which you are required to procure insurance.This should include any helicopters, ultra lights, home-builts, balloons, and experimental aircraft.

FAA # Year Make/Model Total Seats Value

2. List all insureds who are full-time professional pilots by trade along with qualifications.


Pilot/Age Pilot Certificates Ratings Total Hours Make and Model Hours Accident History

3. List all pilot insureds who are not professional pilots, along with qualifications.


Pilot/Age Pilot Certificates Ratings Total Hours Make and Model Hours Accident History