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Insurance Protection Review Survey


from Bailey Place Insurance

Auto Insurance Policy Review

Please complete the form below to help us understand your evolving insurance needs.

Contact Information
Are you the policy holder? ✶

Vehicle Ownership
Registration & Title
Are you or your spouse, the registered and titled owner of your vehicle(s)? ✶
Trusts, Partnerships or Other Ownership
Are any vehicles titled in a trust, partnership, corporation, or owned by two resident relatives other than husband and wife? ✶

Vehicle Usage
Snow Plow Usage
Do you use any of your vehicles to snow plow for others? ✶
(neighbors, businesses, friends, etc.)
Employment Use
Do you use any vehicle for business purposes or in the course of your employment? ✶
Delivery Vehicles
Do you use any vehicle for the delivery purposes? ✶
(newspapers, pizza, etc.)

Driver Information
International Car Rentals
Do you rent vehicles outside the United States? ✶
NYS Defensive Driver
Have you or any household driver taken the NYS Defensive Driver course within the last 3 years? ✶
College Drivers
Do you have children of driving age living at home or away at college? ✶

Other Vehicles
Additional Vehicles
Vehicles not covered by your insurance policy with Bailey Place Insurance? ✶
Employer or Long Term Lease Vehicles
Do you have a vehicle provided for your use through your employer or on a long term lease? ✶
Off-Road Vehicles
Do you own an ATV, snowmobile, motorcycle, golf cart or jet ski? ✶
Recreational Vehicles
Do you own a motorhome, camper, travel trailer or utility trailer? ✶

Coverage Options
Optional Basic Economic Loss (OBEL)
Would you consider adding Optional Basic Economic Loss (OBEL) coverage? ✶
Additional Personal Injury Protection (APIP)
Would you consider increasing your Additional Personal Injury Protection (APIP) coverage? ✶
Uninsured/Underinsured Motorist
Would you consider increasing your Uninsured/Underinsured Motorist coverage? ✶
Increased Deductible
Would you consider carrying a higher deductible on your Comprehensive &/or Collision coverage? ✶
Increased Limits
Would you consider increasing your Liability &/or Property Damage limit? ✶
Rental Reimbursement
Do you want to carry Rental Reimbursement coverage? ✶
Excess Liability
Would you like information on an Umbrella Policy or Excess Liability coverage? ✶
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