In our continuing effort to provide quality service, please take a few minutes to complete this survey. This information will be kept confidential and will assist us to evaluate your insurance needs. Thank you for your assistance.
Please fill out the following form, and then click on the "Submit Review" button.
First Name:
Last Name:
Your email address:
Mailing Address:
Phone work#:
Phone home#:
Where would you prefer us to call you?
home work
Best time to call?:
Your Occupation
Your Employer's Name
Your Date of Birth
Marital Status
Spouse's Name
Spouse's Date of Birth
Spouse's Occupation
Spouse's Employer's Name
Please provide the following information for all other members of your household. Thank you.
Additional Household Member 1
Name
Date of Birth
Driver's License
yes no
Additional Household Member 2
Name
Date of Birth
Driver's License
yes no
Additional Household Member 3
Name
Date of Birth
Driver's License
yes no
Additional Household Member 4
Name
Date of Birth
Driver's License
yes no
Do you own or rent your residence:
own rent
Please answer the following questions by selecting yes or no. Thank you.
Have you done any recent improvements to your home?
yes no
Do you have a swimming pool or a large structure that is not attached to your house?
yes no
Do you have smoke detectors, dead bolts, and fire extinguishers in your house?
yes no
Do you own any high value property such as jewelry, furs, firearms, antiques, collectibles, silverware, coins, stamps, glassware, camera, computer, etc., or do you frequently keep more than $200 at home or on you?
yes no
Do you own any real estate other than your primary home?
yes no
Do you have a wood burning stove?
yes no
Do you own a dog that has ever bitten a person?
yes no
Do you run a business, provide childcare, or store business property at home or on your premises?
yes no
Do you have any children who mow lawns, baby-sit, etc.?
yes no
Do you have any full or part time domestic or residence employees?
yes no
Do you own any type of watercraft, snowmobiles, motorcycles, ATV's, etc.?
yes no
Are any family members away at school?
yes no
How many vehicles do you own?
Do you have a vehicle provided to you that you do not own, i.e., company car?
yes no
Are any of your vehicles titled to anyone other than you and your spouse?
yes no
Are any of your vehicles leased to you?
yes no
Do you use any vehicles for business purposes?
yes no
Do you own any vehicle with electronic equipment (car stereo, speakers, CB, etc.) NOT factory installed, or that has a cap, plow, customizing, or special accessories?
yes no
Are you interested in a quote for adding or increasing any of the following coverages?
Auto liability and uninsured motorist coverages?
yes no
Collision and/or comprehensive auto deductables?
yes no
Towing, rental reimbursement, loan/lease, electronic equipment, customizing, or special accessories that are not factory installed?
yes no
Replacement cost coverage for your home and/or contents?
yes no
Increasing your homeowner liabilty?
yes no
Home business coverage for you and/or your children?
yes no
Earhthquake, flood coverage, or backup of water in your basement?
yes no
Riders for high value property such as jewelry, furs, firearms, antiques, collectibles, silverware, coins, stamps, glassware, cameras, computers, or other types of similar property?
yes no
Credits for dead bolts, fire extinguishers, smoke detectors, security alarms or increasing your homeowner deductible?
yes no
Combining your home and auto policies for possible savings?
yes no
Coverage for boats, snowmobiles, motorcycles, ATV's, or other RV's?
yes no
Are you interested in a quote for medical, dental, or nursing home care insurance?
yes no
Are you interested in a quote for life insurance or disability income insurance?
yes no
Are you interested in a quote for a catastrophic umbrella liability policy which provides additional liability over and above your auto and homeowner liability?
yes no
Are you satisfied with the level of service that we provide you?
yes no
If you had a recent claim, was it settled to your satisfaction?
yes no
Would you consider referring a friend or relative to us?
yes no
Is there anything we could do to improve the service we provide to you?
yes no
If yes, please describe:
Is there anything else you would like to bring to our attention?
Disclaimer: Please be advised that no insurance can be purchased, bound, or put into effect over the GHM Agency website. To start a policy or make changes to an existing policy, you must first speak with a GHM agent who will assist you accordingly. Thank You.
