Wufoo

Mid-Term Policy Exam

WEA Property & Casualty Insurance Company

My name is: First Last
The WEAC member in my family is: First Last
Phone: * ### - ### - ####
Please provide a phone number where you can be reached between 8:00 a.m. and 5:00 p.m.
Home Phone ### - ### - ####
Email
I would like to receive my Mid-Term Policy Exam results by:
Mail Phone E-mail
I would like to receive more information on:
Auto insurance Homeowners/Renters/Condo insurance Additional Liability Insurance (Umbrella) IRA Tax Sheltered Annuity
Liability Protection Assessment Guidelines

Liability protection is the most important protection provided by your insurance policies to prevent catastrophic financial losses. It is not uncommon to be involved in accidents or other situations where you become liable to another individual for injuries, loss of wages, and other damages of $100,000 or more. You don’t want to skimp on liability protection when the cost of higher limits is quite low. We recommend that all WEAC members have liability coverage of $250,000/$500,000 (or $250,000 per person and $500,000 per accident) on auto policies and $500,000 on homeowner, condo owner, and renter policies. We also recommend that most members obtain a personal umbrella liability policy.
Selecting the Right Deductible

The “Deductible” is the amount of a loss you must pay before the insurance policy begins to pay. Deductibles only apply to coverages protecting your property (vehicles, home, or personal belongings) and not to liability protection. You can select deductibles that range from $50 to $5,000. We generally recommend a $250 deductible for auto comprehensive coverage (which covers damage to your vehicle from fire, theft, vandalism, storm damage, glass breakage, and accidents involving animals); $500 for auto collision coverage; and $500 for coverage on your home and personal belongings. The deductible amount you choose is a personal decision that is affected by the extent of your accumulated assets, your annual income, the amount of savings available to pay unexpected expenses, and your tolerance for risk. The higher deductible you choose, the lower the premium. We recommend choosing the highest deductible you can afford to pay in the event of a loss, allowing you to save as much premium as possible. You will pay the higher deductible only IF a loss occurs. If no losses occur, you save money by paying less in premiums.
Risk Tolerance and Loss Sharing
I prefer to pay more premium each year and pay a small portion of a loss if one occurs ($200-$500 deductible). I prefer to pay moderate premiums each year and pay a moderate portion of a loss if one occurs ($500-$1,000 deductible).
Miscellaneous

Please list all the residents of your ousehold who have a drives license (include yourself):

Driver #1
Name First Last
Date of Birth MM / DD / YYYY
Relationship (Self, spouse, child, etc.)
Occupation
Miles to Work or School (one way)
Annual Miles Driven
Driver #2
Name First Last
Date of Birth MM / DD / YYYY
Relationship (Self, spouse, child, etc.)
Occupation
Miles to Work or School (one way)
Annual Miles Driven
Driver #3
Name First Last
Date of Birth MM / DD / YYYY
Relationship (Self, spouse, child, etc.)
Occupation
Miles to Work or School (one way)
Annual Miles Driven
Driver #4
Name First Last
Date of Birth MM / DD / YYYY
Relationship (Self, spouse, child, etc.)
Occupation
Miles to Work or School (one way)
Annual Miles Driven
Miles to Work or School (one way)
AUTO
Please check all that apply:
I have recently paid off a vehicle loan.
Specify vehicle(s).
I have dependents who are full-time students living over 100 miles from home without a vehicle.
List dependent's name(s).
I have driving-age dependents who are full-time students with a 3.0 grade point average or better, or who are in the top 20% of their class.
List dependent's name(s).
I have a vehicle listed on my policy garaged outside the state of Wisconsin.
Specify vehicle(s), location, and which driver has the vehicle.
I have a vehicle listed on my policy that is used for business (other than driving to work).
Specify vehicle(s) and driver(s).
HOME
Please check all that apply:
I have had changes to my mortgage.
Please specify changes.
I have recently purchased personal property such as jewelry, computers, fine arts, boats, or recreational vehicles.
Please specify items.
I own property (land, another home, etc.) that is not listed on my policy.
List location(s).
I have recently made improvements to my home.
List improvements, square footage added, and amount of improvement.
I have outbuildings (detached garage, shed, etc.) on my property.
Describe outbuildings.
I have a swimming pool at my home.
Indicate if your pool is fenced.
I provide care for others in my home for a fee.
Number of people you care for.
I operate a business from my home.
Indicate type(s) of business.
I have a home more than 50 years old and have updated the wiring, roofing, plumbing, and heating system in the last 20 years.
I own a dog.
Specify breed(s).
I own a trampoline.
Please send me information about the following optional coverages:
Rental Reimbursement Emergency Road Service Custom Equipment Backup of Sewer and Drain
Do Not Fill This Out