Personal Risk Management Exposure Survey

Background Information

Date

Named insured:

Street address:

City, State, Zip code

Telephone (home)

Telephone (business)

Fax

Personal e-mail address

Business e-mail address

Next

Real Property Exposures—Land and Buildings

What is the address and value of your primary home?

Is the home more than 40 years old?

 Yes No

Do you own, rent, or lease any other structures located at the main premises such as the following?

Guest or servant quarters

 Yes No

Detached garage

 Yes No

Swimming pool

 Yes No

Fence

 Yes No

Outdoor shed

 Yes No

Barn

 Yes No

Detached greenhouse

 Yes No

Tennis court

 Yes No

Other

 Yes No

For any of the above, provide a description and value

Is the total replacement cost value of the other structures greater than 10 percent of the dwelling limit?

 Yes No

Are the other structures, which are located on the residence premises, rented or leased to other parties?

 Yes No

Is there any business use of the other structures or any storage of business property in these structures?

 Yes No

Do you own, rent, or lease any other structures located away from the main premises, such as the following?

Detached garage

 Yes No

Swimming pool

 Yes No

Fence

 Yes No

Outdoor shed

 Yes No

Barn

 Yes No

Detached greenhouse

 Yes No

Tennis court

 Yes No

Other

 Yes No

For any of the above, provide a description, address, and value

Do you own any other residences?

 Yes No

If yes, provide a description, address, and value:

Do you own any residential property on a time-share basis?

 Yes No

If yes, provide a description, address, and value

Is there more than one owner (besides a resident spouse) of your home or other real properties?

 Yes No

If yes, provide a description, address, and value:

If yes, also provide name and relationship of other owner(s)

Including your primary residence, described above,do you own any condominiums or cooperatives?

 Yes No

If yes, provide a description, address, and value

If yes, is the farm the primary source of your income?

 Yes No

Is the farming incidental or minor in nature?

 Yes No

Does the farming operation involve any employees?

 Yes No

Does the farming operation involve any livestock?

 Yes No

Has any family farmland been transferred to a family limited partnership?

 Yes No

Do you own, rent, or lease from others any vacant land?

 Yes No

If yes, do you have any exposure to hunters using your land to hunt?

 Yes No

Do you have a private airplane landing strip on your property?

 Yes No

If yes, describe and give location

 Yes No

Do other parties, including the general public, have access to these landing strips?

 Yes No

Do you own an option to purchase a residence under a contract for deed or long-term installment contract?(In these deals, the deed or title of the property is transferred only after all the payments have been made.)

 Yes No

Have you sold residential property under a contract of deed?

 Yes No

Do you have the use (or any other interest) of a residence that is held in a trust?

 Yes No

Do any outside parties (other than a traditional mortgagee) have any type of collateral interest in your residence premises?

 Yes No

Are any of your properties located in an area prone to:

Cause of Loss Location
a. Flood
b. Earthquake or volcano
c. Sinkhole or subsidence

Do you store gasoline, any other liquid fuel, or any chemicals in an underground or above ground storage tank on any premises?

 Yes No

If yes, give location/description

Does your home have any lead paint (even if it has been covered by lead-free paint)?

 Yes No

Has your home been renovated or remodeled?

 Yes No

Are you planning any renovations, additions, or new construction during the next 12 months?

 Yes No

If yes, describe below

Do you anticipate purchasing additional real estate in the next 12 months?

 Yes No

If yes, describe below:

Are you a member of a homeowners association?

 Yes No

Are building costs rising rapidly in your community?

 Yes No

Are you confident that your dwelling limits will adequately protect you in the event of a total loss?

 Yes No

Does the replacement cost of your home greatly exceed its market value?

 Yes No

If yes, what is your home’s approximate market value

Do you have a fire alarm or fire protection system in operating order at your residence?

 Yes No

Do you have a finished, lower-level basement in your home?

 Yes No

Do you have a sump pump on your premises?

 Yes No

Next

Personal Property Exposures

Do you have any individual personal property items (e.g., furs, jewelry, fine arts, etc.) valued at over $4,000?

 Yes No

If yes, have you had these valuable items appraised within the last three (3) years?

 Yes No

If the item(s) is a diamond(s) or other precious stone, does the appraisal include a description of its cut, color, clarity, and carat size (4 C’s)?

 Yes No

Do you have numerous low-value items of jewelry, watches, furs, and precious stones in the residence worth more than an aggregate of $1,500?

 Yes No

Are there owned valuable items entrusted, consigned, or loaned out to another party? (e.g., furriers, art dealers or institutes,etc.)

 Yes No

If yes, specify name and relationship:

Describe any security and safeguarding measures in place regarding this entrustment:

Do you speculate or trade in art, jewelry, precious stones or metal, rare coins, or other items of value on an extensive basis?

 Yes No

Are you the owner of a home in a nontraditional family (e.g., same sex domestic partners, adult brother and sister,common-law marriage, two unrelated seniors living together)?

 Yes No

Do you have any dependents who do not reside with you, who are full-time students, and are 24 or more years of age?

 Yes No

Do you have a close relative living in an assisted living care facility or nursing home?

 Yes No

If yes, does this relative own substantial financial assets?

 Yes No

Do you use or own business property valued at over $2,500 on your residence premises or do you own business property valued at over $500 away from your resident premises?

 Yes No

Are any personal property items utilized in a business you own in part or in total?

 Yes No

Do you have extensive computer equipment (e.g., three or more home computers)?

 Yes No

Do you ever keep more than $200 in cash or coins (e.g., coin collection) at your residence?

 Yes No

Do you ever keep more than $1,500 in securities, accounts,deeds, and letters of credit at your residence?

 Yes No

Do you have an inventory of your personal property, including photos or videos, which is stored off-site?

 Yes No

Are you concerned that you may have inadequate limits or protection for your personal property?

 Yes No

Do you have in your home any of the following security or safeguarding measures or devices?

 Yes No

Burglar alarm reporting to a central station

 Yes No

Dead bolts

 Yes No

Property identification program

 Yes No

Neighborhood security service

 Yes No

Carbon monoxide alarms

 Yes No

Fire resistant home safes

 Yes No

Other

 Yes No

Do you store large amounts of meat in freezers?

 Yes No

Next

Business/Professional Exposures

Do you or any of your immediate family members own an interest in an individual proprietorship?

 Yes No

If yes, indicate name/interest:

Do you or any of your immediate family members own an interest in a partnership?

 Yes No

If yes, indicate name/interest

Firm name

Partners

Do you or any of your immediate family members own an interest in a closely held corporation?

 Yes No

If yes, indicate name/interest:

Do you or any of your immediate family members own an interest in a joint venture?

 Yes No

If yes, indicate name/interest:

Do you or any of your immediate family members own an interest in a syndicate?

 Yes No

If yes, indicate name/interest:

Do you or any of your immediate family members own an interest in a foreign business?

 Yes No

If yes, indicate name/interest:

Do you or any of your immediate family members own an interest in a trusteeship (profit or nonprofit)?

 Yes No

If yes, indicate name/interest:

Do you or any of your immediate family members own an interest in any other type of business or commercial venture(besides those previously mentioned) which is operated out of your home, including any interest in a part-time or casual business endeavor?

 Yes No

If yes, indicate name and type of activity

Do you utilize vendors or distributors in your home-based business?

 Yes No

If yes, list the vendors:

Do you have a contractual agreement with any other party (e.g., a contract of sale or a loan agreement) that requires you to carry property insurance that protects their interest in your home business (e.g., by adding them to your policy as a loss payee)?

 Yes No

If yes, list the loss payee(s):

Is your home business involved in law enforcement, retail operations, publishing, media, law, housing, public speaking, or political activities?

 Yes No

Do you ever serve alcohol in connection with your home business?

 Yes No

Do you have valuable home business papers and records worth more than $2,500, including electronic records such as those stored on a computer?

 Yes No

Do you sell a single line of products from one manufacturer or franchiser for your home business?

 Yes No

Do you serve as an executive officer or on the board of directors for any business organizations or homeowners association?

 Yes No

If yes, indicate organization and type of activity:

Do you have a home day care operation at your residence?

 Yes No

Do you now or have you ever practiced a recognized profession (e.g., accountant, lawyer, architect) or performed special services for which you might be liable if you made an error (e.g., notary public, insurance agent, financial adviser)?

 Yes No

If yes, describe profession:

If yes, do you have a professional liability policy, either personally or through your employer?

 Yes No

If yes, list the insurance company and policy number:

Do you travel to countries that present a high risk of being kidnapped?

 Yes No

If yes, list countries, average duration, and average # of trips annually

Has your employer established procedures to follow if an employee is kidnapped?

 Yes No

Next

Automobile Exposures

Are any of your vehicles financed through a bank, credit union, or other financial institution?

 Yes No

Do the owner(s)/lessor(s) of any vehicles you lease requirethat you provide them an additional insured or loss payee status on your personal auto policy?

 Yes No

If yes, indicate vehicles:

Is the outstanding balance of the loan/lease for any of your vehicles greater than the vehicle’s worth?

 Yes No

If yes, indicate vehicle(s)

Would the resell price of any of your vehicles exceed $60,000?

 Yes No

If yes, indicate vehicle(s) value(s):

Does your vehicle(s) have permanently attached (i.e., built-in or bolted on) sound reproducing equipment or other types of valuable communication equipment worth more than $1,000?

 Yes No

Do you use your vehicles to haul property or persons for a fee?

 Yes No

Do you ever rent cars on a short-term basis such as when you travel?

 Yes No

Do you participate in a ride sharing or car-pooling arrangement?

 Yes No

Do you have a good student (B average or better) in your household?

 Yes No

If yes, Name(s):

Have you or other drivers in your household taken defensive driving courses or drug and alcohol awareness programs?

 Yes No

If yes, Name(s):

Do you own a vehicle for which it is difficult to establish a value, such as an antique car?

 Yes No

Do you ever drive into Mexico?

 Yes No

When you do, do you purchase insurance from a Mexican insurer?

 Yes No

Are any vehicles owned by a trust?

 Yes No

If yes, list vehicle(s):

Are you the owner of a small business?

 Yes No

Are any vehicles owned by a family partnership or limited liability company (LLC)

 Yes No

Are there any corporate-owned vehicles that are insured personally?

 Yes No

Is there joint ownership (other than husband and wife) of any vehicles?

 Yes No

If yes, with whom

Does your employer provide you a company car?

 Yes No

. Do domestic employees ever operate your vehicles?

 Yes No

Next

Watercraft Exposures

Do you own any type of watercraft (e.g., boat or jet ski)?

 Yes No

Do you ever lease or rent any type of watercraft?

 Yes No

Is your watercraft ever used for business purposes?

If yes, describe:

Is your watercraft rented or leased to others?

 Yes No

Is your watercraft used to carry persons or cargo for a fee?

 Yes No

Do you employ a crew with any watercraft?

 Yes No

Do you allow many other persons to operate your watercraft for no fee?

 Yes No

Is any watercraft used in pre-arranged or organized races?

 Yes No

Are there other unusual watercraft exposures or situations (e.g., kite surfing, scuba diving)?

 Yes No

If yes, describe:

Next

Aircraft Exposures

Do you or does anyone in your family or the employment of your family have a pilot’s license or do you own or ever rent, charter, or lease aircraft?

 Yes No

Do you or any family members ever charter aircraft with a crew?

 Yes No

If yes, explain:

Do you or any family members ever short-term lease, rent, charter, or use an aircraft acting as pilot or copilot?

 Yes No

If yes, explain:

Do any of your owned or long-term leased aircraft have more than one owner, including any type of fractional ownership?

 Yes No

If yes, list additional owners:

Do you ever fly in aircraft (outside any commercial airlines) in your business activities?

 Yes No

If yes, describe the use, the frequency of the use, and the company:

Do you ever charge anyone for the use of your aircraft?

 Yes No

If yes, explain in detail:

Do you use business-owned aircraft for personal trips?

 Yes No

If yes, describe:

Is/are your aircraft ever used in the instruction of student pilots?

 Yes No

If yes, describe:

Have you entered into a tie down or hangar storage agreement for your aircraft?

 Yes No

If you do not currently own an aircraft, have you ever owned one in the past that you have sold or given away?

 Yes No

Next

Community/Political Activities

Are you involved in charities, churches, political organizations, community action groups, or related organizations?

 Yes No

If yes, list and describe:

If yes, are you a director or officer in any of these organizations?

 Yes No

Do these organizations carry general liability, directors and officers liability, and professional liability policies that protect you?

 Yes No

Do the by-laws of these organizations include a provision that will require them to indemnify you for personal losses arising from activities within the group?

 Yes No

Are audits performed on a regular basis for these organizations?

 Yes No

Are you involved in any activities in a condominium or homeowners association?

 Yes No

If yes, specify the association’s name and your position or role:

Does the association comply with the insurance specifications included in the condominium agreement and the laws of the state?

 Yes No

Do all association members receive detailed information as to the insurance furnished by the association on property and specifically informed as to their personal responsibility for improvements and betterments, contents, and personal liability for individual units?

 Yes No

Does the condominium or homeowners association have property deductibles for common areas that would result in more than $1,000 in assessment exposure to individual unit-owners?

 Yes No

Do you hold any elected or appointed public office or did you hold such a position in the last 5 years?

 Yes No

If yes, describe:

Does this entity carry public officials liability insurance, school board liability insurance, or other appropriate directors and officers liability insurance that protects you?

 Yes No

Do you have a copy of the political entity’s charter or bylaws?

 Yes No

Does an outside party or consulting firm annually evaluate the insurance portfolio of this institution?

 Yes No

Are you legally obligated to furnish a public official bond?

 Yes No

Next

Other Liability Exposures

Are there property easements, access roads, railroad sidetracks, or similar situations on any owned property?

 Yes No

If yes, describe:

Are independent contractors (e.g., lawn, swimming pool, housekeeping services) utilized on your property?

 Yes No

Are alcoholic beverages sold on the premises of investment or rental property you own?

 Yes No

Do you engage in chemical (e.g., pesticide or herbicide) spraying on any owned or leased land?

 Yes No

Are you aware of any safety hazard, attractive nuisance, or unsafe condition on property owned, leased, rented, or controlled by you? (This includes vacant, abandoned, or poorly maintained structures, accumulated debris or cast-off materials on owned land, ponds, trampolines, firearms, etc.)

 Yes No

If yes, describe:

Are you a party to a personal contract, lease agreement, indemnity agreement, employment contract, or similar agreement that requires specific auto, public, or professional liability insurance?

 Yes No

If yes, describe:

Do you engage baby-sitters, groundskeepers, gardeners, nurses, servants, maids, chauffeurs, nannies, or similar persons on a part-time or full-time basis?

 Yes No

If yes, describe:

If yes, are compulsory insurance requirements known and complied with?

 Yes No

Do you have 5 or more personal employees?

 Yes No

Is your residence a historical structure or showcase home?

 Yes No

Do you own or keep inherently dangerous animals (e.g., domesticated animals with biting or clawing history or wild animals such as lions)?

 Yes No

If yes, describe:

Have you earned more than $2,000 in annual compensation concerning any interest in animals trained or bred for races, shows, or commercial breeding purposes?

 Yes No

Do you have personal property of others in your care, custody, or control?

 Yes No

Are you involved in strenuous or risky sports endeavors in which other persons could become injured?

 Yes No

Do you have a lake, pond, ocean, river, or stream on or tangent to any of your properties?

 Yes No

If yes, describe situation and security precautions:

Do you have any other unusual liability exposures or situations?

 Yes No

If yes, describe:

Are the liability limits on any of your underlying policies (e.g., homeowners, personal auto, watercraft) under $300,000?

 Yes No

Next

Overall Program Considerations

Are you, your spouse, trusts, or similar interests specifically and consistently co-named in all of your insurance policies?

 Yes No

Do you retain proposals for insurance that outline exposures and recommended coverage?

 Yes No

Do you discard previous copies of liability (e.g., homeowners, personal auto) policies?

 Yes No

Is your insurance transacted with one agent responsible for your entire portfolio?

 Yes No

Are you provided an annual review of coverage afforded or areas that may be uninsured or underinsured?

 Yes No

Are you provided loss control recommendations by your agent or insurer?

 Yes No

Are you the owner of one or more businesses?

 Yes No

Is your suability factor high? (How suable you are is determined by the size of your savings account and stock portfolio, the size of your real estate holdings, your profile in the community, your family income, and your future income.)

 Yes No

Next

Workers Compensation Exposures

Are you covered under a workers compensation insurance policy in your job?

 Yes No

Health Insurance

Does your employer provide health insurance as part of a group plan?

 Yes No

If yes, indicate insurer:

If yes, indicate coinsurance:

If yes, indicate deductible:

Do you purchase your own individual health insurance plan?

 Yes No

If yes, does your plan contain specific disease limitations?

 Yes No

Insurer:

Co-payment:

Deductible:

Does the individual policy carry burdensome coinsurance and deductible provisions?

 Yes No

Next

Medicare

Are you covered by Medicare?

 Yes No

If yes, do you have a Medicare supplement policy?

 Yes No

Disability Insurance

Does your employer provide short-term disability benefits as part of a group plan?

 Yes No

If yes, what is the duration of the short-term benefits?

Does your employer provide you with long-term disability coverage?

 Yes No

If yes, what is the waiting period between the time you become disabled and the policy begins payment?

 30 days 60 days 90 days 180 days 365 days

Do you purchase your own long-term disability policy?

 Yes No

If yes, what is the waiting period between the time you become disabled and the policy begins payment?

 30 days 60 days 90 days 180 days 365 days

Is your salary greater than $100,000 per year?

 Yes No

Next

Long-term Care

Do you have a long-term care policy?

 Yes No

If yes, specify what insurance company provides coverage:

Financial/Life Insurance

What is your approximate total net worth?

 $100,000 or less $101,000 – $250,000 $250,001 – $500,000 $500,001 – $1,500,000 $1,500,001 – $3,000,000 $3,000,001 – $5,000,000 $5,000,001 – $10,000,000 $10,000,001 – $25,000,000 Over $25,000,000

Please indicate name, occupation, approximate annual salary, and investment income for yourself and members of your household.

Name Occupation Annual Salary Annual Investment Income

In the event of the death of the primary breadwinner, what are the needs for postdeath resources?

Burial fund

Education fund

Dependency income fund

Debt-retirement fund

Estate preservation fund

Total funds:

What are the total assets available to meet these needs?

Savings

Investments

Personal life insurance: term

Personal life insurance: whole

Group life

Social security or other payment

Business interests:

Other:

Total funds:

Are the post-death resources needed greater than the assets available to meet those needs?

 Yes No

If yes, what is the difference? $

Is your wife/husband a stay-at-home spouse?

 yes No

Are you a proprietor, partner, or owner in a closely held corporation?

 yes No

Estate

Do you have a will?

 yes No

If yes, when was it last updated?