Risk Management Report Card

The relationship which we desire to have with you is based on the fact that you believe you can trust us to assist you with the necessary safeguards that can help manage your risk factors in life. To enable us to be in the best position to assist you, it is critical that our relationship is based on effective, timely, and accurate communication, which is both given and received from each.

This optional form is designed to assist both of us as we work together and covers many, but not necessarily all possible risk factors you are confronted with. If there are other risk factors you feel we should consider or have questions with please let us know. This exercise can assist us to position you for the best possible premiums and less risk. Our goal is to have this completed 120 days before your insurance renewal.

Thanks for working with us as we seek to do our best to assist you in managing your risk factors that can rapidly change in our culture today.

Client information

Name:
Address:
Policy Number:
Email:
Telephone:

[Property Risk Factors]

	Question
1	Do you have a personal property inventory completed, which is current?	Yes No NA
2	Do you have a schedule completed for portable equipment, jewelry, art, antiques, collectibles, other appreciating or rare items on file with our office, which is current?	Yes No NA
3	Are there current appraisals for portable equipment, jewelry, art, antiques, collectibles, and other appreciating or rare scheduled items that you wish to insure on file in our office?	Yes No NA
4	Do you own any self-powered home and lawn maintenance items such as riding mowers, lawn tractors, snow throwers, etc?	Yes No NA
5	If the answer to question 4. is "Yes" then provide details:
6	Have you developed a crisis plan that could be activated in case of an emergency?	Yes No NA
7	Have you conveniently placed flashlights that work, should a possible emergency happen that would require their use?	Yes No NA
8	Have you conveniently placed a radio with good working batteries that can assist you if needed for an emergency?	Yes No NA
9	Is a central station or other alarm certificate on file in our office?	Yes No NA
10	Have you checked to be sure there is no torn carpeting or defective flooring that could create trips and falls?	Yes No NA
11	Are all exit ways checked for a "clear exit path" and a working flashlight is available?	Yes No NA
12	Have smoke detectors been inspected and tested in the last 12 months?	Yes No NA
13	Have carbon monoxide (CO) detectors been inspected in last 12 months?	Yes No NA
14	Fire extinguishers inspected/serviced in last 12 months?	Yes No NA
15	Heating & Air Conditioning units serviced in last 12 months?	Yes No NA
16	All flammables are stored three feet or more from heating and mechanical units?	Yes No NA
17	Have you checked to be sure there are no improper use of extension cords or any used that are in poor condition?	Yes No NA
18	Have you checked to be sure there are no exposed wires, broken outlets, or other malfunctioning electrical items present?	Yes No NA
19	Have you checked to be sure there no over loaded outlets?	Yes No NA
20	Is there lightening protection and power surge protection for electronic equipment?	Yes No NA
21	Are lightening rods installed?	Yes No NA
22	Does all of your plumbing function properly, with no known leaks?	Yes No NA
23	Have you checked to be sure there is no visible interior or exterior water or mold damage?	Yes No NA
24	Are all down spouts and eves in good working order and direct water away from the building?	Yes No NA
25	Is your roof is in good repair?	Yes No NA
26	What is the age of roof?
27	Have you checked to be sure there are no visible structural hazards such as cracks in walls, foundation or bowed/bulging walls?	Yes No NA
28	Have you checked to be sure there are no tuck-points (mortar joints between bricks), for you home, needing repair?	Yes No NA
29	All windows and frames are in good repair, and properly caulked?	Yes No NA
30	All property exteriors are in good repair and do not lack paint?	Yes No NA
31	Is all property free of graffiti?	Yes No NA
32	Are all trees in good condition with no broken, dead or dying limbs?	Yes No NA
33	Are all fences in good repair?	Yes No NA
34	Was your chimney cleaned and inspected for cracks and other defects in the last 12 months?	Yes No NA
35	Are all decks and elevated walkways in good condition?	Yes No NA
36	Are there detached buildings on your property used for a business use?	Yes No NA
37	Is there a home business operated from your home?	Yes No NA
38	Good housekeeping is evident both inside and outside of your property?	Yes No NA
39	All indoor and outdoor stairways have properly working sturdy handrails?	Yes No NA
40	All outside steps and sidewalks are in good repair with no cracking or uneven surfaces?	Yes No NA
41	Are parking areas and driveways in good repair with no potholes or other trip and fall hazards?	Yes No NA
42	Is your key distribution policy adequately restrictive?	Yes No NA
43	Are all exterior doors and locks in good repair?	Yes No NA
44	Does exterior property lighting provide adequate risk management and are they properly maintained?	Yes No NA
45	Are all flammables properly stored and secured, especially from children?	Yes No NA
46	Are all cleaning chemicals properly stored and secured, especially from children?	Yes No NA
47	Is your fireplace or wood stove regularly cleaned and inspected?	Yes No NA
48	Are all lawn and garden tools properly maintained?	Yes No NA
49	Is your swimming pool properly maintained and fenced?	Yes No NA
50	Are pets properly trained and secured?	Yes No NA
51	Are your pets in good physical health? When was last physical?	Yes No NA
52	What pet do you currently have or plan on owning in the near future?
53	Is all playground equipment in good repair with proper fall-absorbing materials/ground surface covering?	Yes No NA
54	Does your trampoline have properly safety features and in good repair?	Yes No NA
55	Do you do background checks for those that may care for your children?	Yes No NA
56	Has any property been remodeled recently or do you plan on doing remodeling in near future?	Yes No NA
56	Details:
57	Have all property updates, additions, newly built or purchased buildings or personal property been reported to our office ?	Yes No NA
58	Do you request proof of insurance and workers comp for those working on your property?	Yes No NA
59	Are portable electronic devices properly secured when away from home?	Yes No NA
60	Is ice and snow removed from walkways with 24 hours or as required by community ordinance?	Yes No NA

[Household Driver Risk Factors]

	Question
1	Do have an understanding with drivers in your household under the age of 19 that they will only allow one unrelated passenger?	Yes No NA
2	Do you allow no more passengers in your vehicles then legally allowed for each seat?	Yes No NA
3	Are you careful to not be impaired by alcohol or drugs when driving?	Yes No NA
4	Are you careful to not be impaired by a required medication when driving?	Yes No NA
5	Do you refrain from the distraction of grooming when driving?	Yes No NA
6	Do you refrain from the distraction of smoking when driving?	Yes No NA
7	Do you refrain from the distraction of reading maps or other printed material when driving?	Yes No NA
8	Do you refrain from text messaging material when driving?	Yes No NA
9	Do you habitually use your seatbelt and encourage your passengers to do the same?	Yes No NA
10	Do you have a cell phone available in case of an emergency when driving?	Yes No NA
11	Have you had vision test in the last two years?	Yes No NA
12	Are sunglasses available in your vehicle for sun glare reduction ?	Yes No NA
13	Are personal property items in your auto secured from view to deter theft when the auto is left parked?	Yes No NA
14	Do you allow non-family members to drive your vehicle?	Yes No NA
15	Are you careful to never leave a child or pet in an unattended vehicle?	Yes No NA

[Household Vehicle Risk Factors]

	Question
1	Is there regular scheduled maintenance for each owned vehicle?	Yes No NA
2	Have you checked your windshield for cracks and stone chips?	Yes No NA
3	Are the rearview mirror and side mirrors functioning properly?	Yes No NA
4	Have you inspected your brakes and parking brake?	Yes No NA
5	Have you recently inspected your spare tire for proper inflation?	Yes No NA
6	Do you regularly check your tires for proper inflation?	Yes No NA
7	Do you regularly check your tires for unusual tire wear which can indicate tire, suspension, or drive train problems?	Yes No NA
8	Have you checked your jack to be sure it is in good working condition and that you can safely use it?	Yes No NA
9	Do you have vehicle safety kit in each vehicle?	Yes No NA
10	Do you have a fire extinguisher in each vehicle?	Yes No NA
11	Do you have a first aid kit in each vehicle?	Yes No NA
12	Are the appropriate child car seats available when needed and do you know how to properly install them to meet the new legal requirements?	Yes No NA
13	Have you recently checked the working condition of headlights, tail lights and all warning lights of the vehicle?	Yes No NA
14	Has the vehicle exhaust system been inspected?	Yes No NA
15	Do you always lock your vehicle when leaving and take the keys with you?	Yes No NA
16	Are all vehicles listed on your policy titled to the named insured?	Yes No NA
17	Are all household drivers listed on the policy?	Yes No NA
18	Are any vehicles parked overnight on a public street?	Yes No NA
19	Does anyone in the household drive a company provided vehicle?	Yes No NA
20	Do you own any recreational items such as campers, travel trailers, watercraft, golf carts, dune buggies, go-carts, mopeds, Segways, snowmobiles or any item capable of flight.	Yes No NA
21	If the answer to question 20 is "Yes" then provide details:
22	If you allow non-family members to operate any of the equipment listed in question 20 do you provide adequate instruction and controls?	Yes No NA
23	Do you maintain the items listed in question 20 as recommended by the manufacturer?	Yes No NA

[Risks You Review Habitually Before You Vacation]

	Question
1	Before you drive your own vehicle do you perform an inspection of moving parts, hose, battery, belts, tires, brakes etc?	Yes No NA
2	Do you regularly check auto fluid levels, especially before traveling on vacation?	Yes No NA
3	Do you stop the mail and newspaper or have someone pick them up on a timely basis?	Yes No NA
4	Do you make arrangements for your grass to be mowed and walks shoveled while you are away?	Yes No NA
5	Do you have a trusted neighbor that can watch over things while you are away?	Yes No NA
6	Do you secure all doors and windows?	Yes No NA
7	Do you shut off the main water valve?	Yes No NA
8	Do you check that the refrigerator and freezer are securely plugged into the outlet?	Yes No NA
9	Do you make sure all bills (including insurance) are paid current?	Yes No NA
10	Do you make sure you have the proper amount of required medications?	Yes No NA
11	Do you make sure you have the proper amount of sleep before traveling?	Yes No NA
12	If you have physical issues that can affect your driving, have you cared for them in the best way before you travel ?	Yes No NA

[Other Risk Factors]

	Question
1	Do you have important paperwork such as wills, deeds, titles and other important documents organized with the location known by those that may need them?	Yes No NA
2	Are your wills, trusts and other end of life paperwork activated and current?	Yes No NA
3	Are your insurance policies for property and vehicles properly listing the title holder as the named insured?	Yes No NA
4	Are all vehicles owned and operated by a resident of your household listed on your auto policy?	Yes No NA
5	Have we insured all real estate and personal property titled to any resident of your household?	Yes No NA
6	Do any household members serve in any volunteer community or church position such as a director, officer, teacher, or other leadership?	Yes No NA
7	Are there privacy issues for data on your notebook and other equipment?	Yes No NA
8	When was the last time you reviewed your property, vehicle, life or other insurance so that you know you are properly covered and understand new benefits and changes?
9	What do you believe to be your greatest safety and security challenge and what actions have you taken to meet that challenge?

[Signature]


I declare that all of the above data given in this document regarding hazards as well as all other information contained herein, is true, complete and correct to the best of my knowledge and belief. I am aware that this statement is material to the company in determining my eligibility for insurance and applicability of available discounts. I understand that any person who submits a request for an insurance discount knowing that it contains a false or deceptive statement may be guilty of insurance fraud, which is a crime. Penalties may include imprisonment, fines and civil damages.
	Printed signature of policyholder reviewing this form:
	Date Signed

[Agent Section]

	Question
1	Year last Property Valuation Report was completed?
2	Agent comments from review of of claims history
3	Claim free status:
4	Other Agent Notes:
5	Name or signature of agency representative personally reviewing this form with the client:
6	E-mail address of agency representative personally reviewing this form with the client: