Insurance Checklist "*" indicates required fields 1Basic Information2Home Checkup 3Auto Checkup Client Name* First Last What is your preferred method of contact?* Email Phone call Text message Other We use text messaging to communicate with clients about their policies (not for marketing purposes). Can we send you text/SMS messages?NoYesBy selecting ‘Yes,’ you consent to receive text/SMS messages from Ullrich Insurance.Preferred Email Address* Preferred Phone Number*What concerns do you have about your insurance?Are all of your personal insurance policies with Ullrich Insurance?*Why do we ask? If you have insurance policies elsewhere – such as for a rental property, classic car, or boat – we want to make sure you don’t have any dangerous gaps in protection. Yes No General Life ChangesThe following life events can impact all your insurance policies. Please select all that apply. Had a baby Got married or engaged Separated or got divorced Purchased an investment property Someone moved into or out of your household (including a child) Your child turned 18 General discount checkupThe following discounts may apply to your home or auto insurance policies. Select all that apply. College graduate University of Washington graduate School employee discount Home Discount ChecklistThe following discounts may apply to your home, condo, or renters insurance policy, even if your alarms are self-monitored (such as with Nest Protect or SimpliSafe). Please select all that apply. Fire alarm Burglar alarm Gas alarm (such as a carbon monoxide alarm or automatic gas main shut-off) Water alarm (such as a water leak sensor or automatic water shut-off) Non-smoker Life Changes That Impact Home InsuranceThe following life changes may impact your home, condo, or renters insurance policy. Please select all that apply. Completed a home remodel, improvement, or addition Purchased or inherited high value items like jewelry, firearms, or artwork Purchased an outdoor trampoline Began renting out your home, either on a long term or short-term basis (like Airbnb) Started a home based business or have a hobby that earns income Serve on the board of a nonprofit, including a homeowners association Adopted a pet Vehicle Usage*Your insurance company may have new discounts available based on your vehicle usage. Please provide the following for each car you own: primary usage (such as pleasure or commute), commute distance one way (if applicable), and annual miles driven.Auto Discount ChecklistThe following discounts may apply to your auto policy. Please select all that apply. Driver safety course completion (age 55+) AAA member Child good student discount (3.0 GPA or higher) Child away at college (75+ miles from or more) without a car Low mileage (8,000 miles a year or less) Life Changes that Impact Auto InsuranceThe following life changes may impact your auto policy. Please select all that apply. Recently paid off a loan or lease for one of your cars Have (or will have!) a teen driver Changed jobs or retired Drive for work, such as for real estate agent or pizza delivery Began driving for Uber, Lyft, Amazon Flex, or a similar company Purchased an ATV, motorcycle, or other motorized vehicle We're always striving to improve. We welcome a few words of feedback if there's anything we can do to better serve you. Thank you!
