Obtain the Declarations Page of Your Homeowner's Policy and Fill In the Following Table: Named Part A Inflation Part B Part II Part E Part F Deductible Peril or Endorsement Part D Medical Company} Form Dwelling Other Personal Personal Liability Open Peril Loss of Use Payments to Coverage Structures Property limit Coverage Others Eg; State Farm Clpen peril 5 res,- 4% 10% of 50% of 30% of 5300.000 $1.000 per [HCI 5} except Replacement Dwelling Dwelling Dwelling Minimum person per Comprehensive exclusions Value Coverage Coverage Coverage recommendation incident Form Your Poll cy: List any added endorsements: eg. earthquake, jewelry. collectibles, home office, etc. List Discounts Currently Applied: eg. Property protection devices. multi policy discount. Tallr. to your agent about possible other discounts. I havetaken a household inventor and it is held in a safe My deductible matches my ability to pay out of pocket for losses. Circle Clne; 'i'es No I have read the exclusions that are part of my_policy. Some may surprise you! Circle One: res No lace outside the home. Circle One: Yes No Obtain the Declarations Page of Your Auto Policy and Fill in the Following Table {only 1 car required}; Company Eg. State Farm Auto liability Coverage 5250.000 each person bodily injury ssoopon each occurrence bodily injury 5250.000 property damage Unlnsuredenderinsu red Motorists Covera_ e 92 50.000 eac h person bodily inj u ry ssooooo each accident bodily injury 52 50.000 property damage $1.000 each person Auto Collision Coverage Actual Cash Value 9500 Deductible Auto Comprehensive Covera_ e Actual Cash Value 3500 Deductible Annual Premium Rental Reimbursement Upto $25 per day for a maximum of S?50 per accident Ded uctih le $500 Your Poll cy: List Discounts Applied: Multi policy, good student discount, etc. Since my auto is older C 8+ years]. I have checked with my agent to see if comprehensive and collision coverage still makes sense? Circle one: 'res No Not applicable My deductible matches my ability to pay out of pocket for losses. Circle one: Yes No Does the liability coverage on your homeowner's and auto polity cover at a minimum the value of your net worth? Circle One.- res No umbrella liability_policy to coordinate with your homeowner's and auto policy. If the answer is no. talk to your agent about a possible