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Personal Insurance Renewal Information

What's changed this year?

Completing this form is all about making sure that we're protecting the right things for you. Thanks for taking a moment to update your information.

Let's make sure we understand any changes to your world.

Step 1 of 4

25%

Your Name*
First Last
Phone*
Email*
Where do you work?*

This can sometimes provide a discount.
Do you have a spouse or partner living with you?*
- Yes
- No
Spouse or Partner Name*
First Last
Spouse or Partner Phone
Helpful but not necessary
Spouse or Partner Email

Helpful but not necessary
Where does your spouse or partner work?*

Discount may apply
Are you married?*
- Yes
- No
Discount may apply

Do you rent or own your home?*
- Rent
- Own
Have you moved in the last year?*
- Yes
- No
Current Address (where you live now)*
Street Address City State ZIP Code
Old Address (Where you lived before)*
Street Address City State ZIP Code
Which bank helps you with your mortgage?*

This helps us make sure they get the right documents
What is the age of your roof?*
What material is your roof?*
- Asphalt Singles
- Metal
- Shake
- Other
Which of the below do you have?*
- Detached Garage / Pole Barn
- Pool
- Finished Basement
- Woodstove
- Trampoline
- Security System
- None
Does your trampoline have a safety net?
- Yes
- No
What size is the detached garage / pole barn?*

give us a ballpark idea
Is the pool:
- In Ground
- Above Ground
Does the pool have:*
- Diving Board
- Slide
- Neither
Does the pool have a fence or electric cover?*
- Yes
- No
How deep is the deepest part of the pool?*
Do you have a sump pump?*
- Yes
- No
Does the sump pump have battery backup?*
- Yes
- No
What type of Security System?*
Do you have any valuable collectibles?*
- Yes
- No
Think jewelry, fine art, vehicles, etc.
Please share a description and value?*

Please list all cars in your household (year/make/model)*
Are there any additional drivers in your home?*
- Yes
- No
Name & birthdate of any additional drivers in your home*
Are any drivers your children?
- Yes
- No
Do they have a B average in school or higher?
- Yes
- No
Do any cars have loans on them?*
- Yes
- No
Which cars & who is the lender?

Additional Comments or Information
Any feedback you want to share about the Shine experience over the last year?
Comments
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Contact

812.679.8779
101 W Kirkwood Ave
Suite 134
Bloomington, IN 47404

Business hours

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Friday 9am-12pm

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