Client Annual Review 
Contact Information
First Name:
 *
Last Name:
 *
Address:
City:
State:
Zip Code:
Home Phone
Work/Cell Phone
Email Address:
 
Automobile/Vehicle
Would you consider increasing your deductible to lower your premium?
Do we currently insure all of the vehicles in your household?
If not how many do you insure elsewhere?
Are all of the licensed drivers in your household listed on your auto policy?
Would you like to include your car stereo (if mounted under the dash) tapes CD's CB or two-way radio on your auto policy for an additional premium?
If you own a pickup or a van does it contain any customized equipment?
Do you own a pickup camper or camper shell?
Do you own minibikes mopeds or motorcycles?
If so how many?
Do you have vehicles furnished for regular use that you do not own such as a company car?
If so how many?
Do you want rental reimbursement or towing and labor coverage in the event that your car is damaged in an accident?
Do you own any boats motorbikes motor homes or other recreational vehicles such as snowmobiles or golf carts?
Would you like a quote for higher limits of liability insurance or personal injury protection?
Do you have other electronic devices you with to cover (e.g. cell phone)?
 
Homeowner/Renter/Condos
Do you own any antiques fine arts or collections such as unique dishes and figurines? (Please note coverage may be limited or excluded under your policy).
Do you own any jewelry or furs? (Please note coverage may be limited or excluded under your policy).
If so what is the total appraised value of those items?
Do you own valuable camera equipment silverware or guns? (Please note coverage may be limited or excluded under your policy).
Do you frequently carry or keep in your home more than $100 in cash? (Please note coverage may be limited or excluded under your policy).
Do you have a coin or stamp collection? (Please note coverage may be limited or excluded under your policy).
Would you prefer to cover your personal belongings for their full replacement value (i.e. no deduction for depreciation)?
Would you be interested in adding earthquake insurance to your homeowners protection?
Would you be interested in adding flood insurance to your homeowners protection?
Do you currently have a burglar alarm?
Do you currently have a fire alarm?
Do you currently have a smoke alarm?
Do you currently have fire extinguishers?
Do you currently have dead bolts on all doors in your home?
Would you like an estimate of your home's replacement cost at today's prices?
Would you like home replacement guarantee protection?
Do you own a second home or any other real property such as a cabin farm property or any income producing property?
Are you engaged in any form of farming or ranching?
Do you conduct any business (including child care) or give private lessons in your home?
Would you be interested in an umbrella or excess liability policy that extends your auto and homeowners liability coverage to $1 million or more?
Do you own a computer for personal use?
Do you own a computer for business use?
 
Other Personal Insurance
Do you maintain a website?
Do you have disability income insurance in case you became sick or disabled?
Are you aware that accidental death and disability insurance for you and your family is available at low cost?
Do you have a mortgage redemption insurance policy (which pays off your house in the event of your death)?
Are all members of your family protected by life insurance?
Would you like a review of the beneficiaries ownership and cash values (if any) of your life insurance policies?
Are you interested in discussing life insurance within the next year?
Is your health insurance up to date? (Consider recent increases in hospital rates).
If you are a self-employed professional would you like a quote for your business property professional liability or malpractice insurance?
 
By completing this form you are acknowledging your understanding of and agreement with the following terms:
1. No coverage of any kind is bound or implied by submitting information via this online form.
2. Information from you and other sources such as your driving claims and insurance histories may be used to calculate an accurate price for your insurance.
3. We will not distribute information to other parties other than for insurance underwriting purposes.
4. We value your privacy. Every precaution has been taken to insure your privacy and security.
5. By submitting this form you agree to release us from any liability should this information be accidentally viewed by others.
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We currently provide insurance services in: 
  • North Carolina
  • South Carolina
  • Virginia

    Please note: Changes to policies via this website are not effective or binding until you, or any party involved, receive official notification from your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

    First Casualty Insurance Group, Inc.
    190-A Turner Street
    Southern Pines, NC 28387
    1-800-352-3416
    fciginfo@fcignc.com
     
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