March 2007, Volume 3
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Category: Personal Risks

Checklist Instructions:

Agent: The coverages listed below are suggested. After evaluating each of the listed coverages, check "Recommend" by those that apply specifically to this client. Make sure both the exposure and the coverage are explained to the client. Each coverage and option is explained in the Definitions section of this program.

Client: For each of the coverages that the agent has recommended, initial whether you have chosen to accept or reject that coverage in the blanks provided.

COVERAGE CHECKLIST

 Recommend Accept Reject
HOMEOWNERS
Coverage Forms
Homeowners 2-Broad Form ______ ______ ______
Homeowners 3-Special Form ______ ______ ______
Homeowners 4-Contents Broad Form ______ ______ ______
Homeowners 5-Comprehensive Form ______ ______ ______
Homeowners 6-Unit-owners Form ______ ______ ______
Homeowners 8-Modified Coverage Form ______ ______ ______
Property Endorsements Recommend Accept Reject
Actual Cash Value Settlement ______ ______ ______
Actual Cash Value Loss Settlement - Windstorm or
Hail Losses to Roof
______ ______ ______
Actual Cash Value Mobilehome ______ ______ ______
Additional Insured - Residence Premises ______ ______ ______
Additional Insured - Student Living Away From the Residence Premises ______ ______ ______
Additional Interests - Residence Premises ______ ______ ______
Additional Limits Of Liability - Coverages A, B, C & D ______ ______ ______
Assisted Living Care Coverage ______ ______ ______
Building Additions and Alterations (Other Residence Location) ______ ______ ______
Coverage B-Other Structures Away from the Residence Premises ______ ______ ______
Coverage C - Increased Special Limits of Liability ______ ______ ______
Credit Card, Electronic Funds Transfer Card or Access Device,
Forgery and Counterfeit Money Coverage (Increased Limits)
______ ______ ______
Earthquake ______ ______ ______
Extended Theft Coverage for Residence Premises
Occasionally Rented to Others
______ ______ ______
Fire Department Clause ______ ______ ______
Functional Replacement Cost Loss Settlement ______ ______ ______
Identity Fraud Expense Coverage ______ ______ ______
Increased Limits on Personal Property in Other Residences ______ ______ ______
Inflation Guard ______ ______ ______
Landlord?s Furnishings ______ ______ ______
Limited Fungi, Wet or Dry Rot, or Bacteria Coverage ______ ______ ______
Livestock Collision Coverage ______ ______ ______
Loss Assessment Coverage (Unit-owners) ______ ______ ______
Loss Assessment Coverage - Earthquake (Unit-owners) ______ ______ ______
Mobilehome Endorsement ______ ______ ______
Ordinance or Law Increased Amount of Coverage ______ ______ ______
Other Members of Your Household ______ ______ ______
Other Structures on the Residence Premises (Increased Limits) ______ ______ ______
Owned Motorized Golf Cart Physical Loss Coverage ______ ______ ______
Permitted Incidental Occupancies ______ ______ ______
Personal Property at Other Residences - Increased Limit ______ ______ ______
Personal Property Replacement Cost Loss Settlement ______ ______ ______
Property Remediation for Escaped Liquid Fuel Coverage ______ ______ ______
Property Removed Increased Limit ______ ______ ______
Refrigerated Property Coverage ______ ______ ______
Replacement Cost Loss Settlement for Certain Non-Building
Structures on the Residence Premises
______ ______ ______
Residence Held in Trust Coverage ______ ______ ______
Scheduled Personal Property Endorsement ______ ______ ______
Sinkhole Collapse ______ ______ ______
Special Computer Coverage ______ ______ ______
Special Loss Settlement ______ ______ ______
Specific Structures Away From the Residence Premises ______ ______ ______
Specified Additional Amount of Insurance for Coverage A-Dwelling ______ ______ ______
Structures Rented To Others Endorsement (Residence Premises) ______ ______ ______
Unit-owners Coverage A Special Coverage ______ ______ ______
Unit-owners Coverage C Special Coverage ______ ______ ______
Unit-owners Rental to Others ______ ______ ______
Water Backup and Sump Discharge or Overflow ______ ______ ______
Windstorm / Hail Deductible (Percentage) ______ ______ ______
Required State/Other Specific Endorsements (List)
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
Liability Endorsements Recommend Accept Reject
Additional Insured (Residence Premises) ______ ______ ______
Additional Insured - Student Living Away From the Residence Premises ______ ______ ______
Additional Residence Rented to Others (1, 2, 3 or 4 Families) ______ ______ ______
Assisted Living Care Coverage ______ ______ ______
Farmers Personal Liability ______ ______ ______
Incidental Farming Personal Liability ______ ______ ______
Incidental Low Power Recreational Motor Vehicle ______ ______ ______
Other Members of Your Household ______ ______ ______
Owned Snowmobiles ______ ______ ______
Permitted Incidental Occupancies (Other Residence) ______ ______ ______
Personal Injury ______ ______ ______
Property Remediation for Escaped Liquid Fuel Coverage ______ ______ ______
Residence Held in Trust Coverage ______ ______ ______
Section II ? Limited Coverage for Year 2000 Computer Related
and other Electronic Problems
______ ______ ______
Structures Rented to Others ______ ______ ______
Watercraft Liability ______ ______ ______
Other Endorsements (List)
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
In-Home Business Endorsements Recommend Accept Reject
Additional Insured - Managers or Lessors of Premises Leased
to an Insured
______ ______ ______
Additional Insured - Vendors ______ ______ ______
Business Pursuits ______ ______ ______
Home Business Insurance Coverage ______ ______ ______
Home Day Care Coverage Endorsement ______ ______ ______
Increased Limits on Business Property ______ ______ ______
Liquor Liability Exclusion and Exception for Scheduled Activities ______ ______ ______
Section I - Property Coverages for Home Day-Care Business ______ ______ ______
Sections I and II ? Limited Coverage for Year 2000 Computer Related
and other Electronic Problems
______ ______ ______
Special Coverage - Spoilage of Perishable Stock ______ ______ ______
Special Coverage for Valuable Papers and Records ______ ______ ______
Valuable Papers and Records Coverage Increased Limits ______ ______ ______
Other Endorsements (List)
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
PERSONAL AUTO COVERAGE
Personal Auto Policy Coverages Recommend Accept Reject
Liability ______ ______ ______
Damage to Your Auto ______ ______ ______
P.I.P. ______ ______ ______
Uninsured Motorist ______ ______ ______
Underinsured Motorist ______ ______ ______
Medical Payments ______ ______ ______
Automobile Endorsements Recommend Accept Reject
Additional Insured-Lessor ______ ______ ______
Auto Loan / Lease Coverage (Lease-Gap) ______ ______ ______
Coverage for Damage To Your Auto (Stated Amount) ______ ______ ______
Customizing Equipment Coverage ______ ______ ______
Excess Electronic Equipment Coverage ______ ______ ______
Extended Non-Owned Coverage - Vehicles Furnished or Available
for Regular Use
______ ______ ______
Extended Non-Owned Coverage - Vehicles Furnished or Available
For Use as Public or Livery Conveyances
______ ______ ______
Federal Employees Using Autos in Government Business ______ ______ ______
Joint Ownership Coverage ______ ______ ______
Liability Coverage Exclusion ______ ______ ______
Limited Mexico Coverage ______ ______ ______
Loss Payable Clause ______ ______ ______
Miscellaneous Type Vehicle ______ ______ ______
Miscellaneous Type Vehicle Amendment (Motor Home) ______ ______ ______
Named Non-Owner Coverage ______ ______ ______
Optional Limits Transportation Expenses Coverage ______ ______ ______
Snowmobile Endorsement ______ ______ ______
Towing and Labor Costs Coverage ______ ______ ______
Trailer/Camper Body Coverage (Maximum Limit of Liability) ______ ______ ______
Trip Interruption Coverage ______ ______ ______
Trust Endorsement ______ ______ ______
Required State/Other Specific Endorsements (List)
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
ADDITIONAL POLICIES Recommend Accept Reject
Aircraft Hull / Liability Policy ______ ______ ______
Dwelling Property Policy ______ ______ ______
Flood Insurance Policy ______ ______ ______
Foreign / International Travel Policy ______ ______ ______
Personal Inland Marine Policy ______ ______ ______
Personal Liability Policy ______ ______ ______
Personal Umbrella Policy ______ ______ ______
Professional Liability Policy ______ ______ ______
Recreational Vehicle Policy ______ ______ ______
Terrorism Coverage Policy ______ ______ ______
Watercraft (Yacht) Policy ______ ______ ______
Workers Compensation Policy ______ ______ ______
Other Policies / Exposures (List)
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
Company Specific Coverage Options
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
Company Mandatory/Required Forms and Endorsements
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______
________________________________________ ______ ______ ______

I certify that I have reviewed my coverage needs in accordance with this checklist with my agent and I have accepted or rejected the recommended coverages as indicated by my initials in the spaces above.

___________________________________ Signature of Client ______________________ Date

_____________________________________________ Title

I certify that I have reviewed the coverages outlined in this checklist with my client and that the initials of the client indicate the acceptance or rejection of the coverages recommended.


___________________________________ Signature of Agent _______________________ Date