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Annual Insurance Checklist

Name: Goebel Insurance Agency, Inc.
Address: 2026 S 12th St, Philadelphia, PA, 19148, US
Telephone: (215) 465-9311

First Name*
Last Name*
Call Phone*
Best Email*
Which type of insurance do you have with us? Select all that apply.*
- Personal Insurance
- Business Insurance
Personal Insurance
Are you married or single?
Comments
How many people reside in your house hold regardless of age?
Do we need to Add or Remove anyone from your policy?
Comments
How many vehicles are registered to you or to your address?
Do we need to Add or Delete any vehicles for you?
Comments
Are any vehicles being driven by others?
Please provide their names.
Comments
Do we need to Add or Delete any drivers? (All residents age 16 or older are required to be listed on the policy as a Driver or as a Non-Driver.)
Please provide their names.
Comments
All residents of your house hold need to be listed on your policy either as a driver or non driver.
Name Driver / Non-Driver
Comments
Any tickets or moving violations in the past 3 years for anyone?
If Yes, please provide drivers name, date of violation, and violation description.
How many miles do you drive to work? How many miles do you drive per year? Please answer per vehicle listed on your policy.
Miles to work Annual Miles Vehicle
Comments
Do you use any vehicle for Business Use? Uber, Lyft, Delivery, Contracting, Realtor etc. Drive to work is not Business Use.
Comments
Would you like a quote for Rideshare or Business Use? ( Uber, Lyft, Delivery, Contractor, Realtor etc )
Comments
Has any driver in the house had their drivers license suspended or revoked in the past 3 years?
If yes, please list name, date of suspension and the reason why.
Where are your vehicles parked/garage/kept when not in use?
Comments
Do you Own or Rent your home?
Comments
Home Address
Street Address Address Line 2 City State ZIP Code
How is your home occupied?
Comments
Do you own any pets?
If you have a pet please list how many pets, types, breeds etc
Has any pet ever bitten anyone?
Comments
Have you renovated, remodeled, added on to, or otherwise updated your home(s)?
- Yes
- No
Comments
Do you have plans for any major renovations, other than cosmetic repairs?
- Yes
- No
Comments
Overall condition of house?
- Poor
- Fair
- Good
- Excellent
Comments
Are there any current damages to your Home right now? ...Roof leaks, pipe leaks, etc.
- Yes
- No
If yes, please describe
Have you started a business based out of your home?
- Yes
- No
Comments
Do you have:
- Smoke Alarms
- Carbon Monoxide Alarms
- Monitored Alarms
- none
Do you protect your home with a professional security system?
- Yes
- No
Comments
Have you added a permanent swimming pool?
- Yes
- No
Comments
Do you or any family members perform babysitting services in your home?
- Yes
- No
Comments
Do you employ any part-time or full-time domestic help, including nannies, housekeepers, or landscapers?
- Yes
- No
Comments
Have you purchased any additional residences such as condos, timeshares, or second houses?
- Yes
- No
Comments
Do you rent out your home as part of the home-sharing economy?
- Yes
- No
Comments
If you’ve started renting out your home or any other property, do you have renters insurance?
- Yes
- No
Comments
Do you operate a business from home?
- Yes
- No
Comments
Do your Business clients ever visit your home?
- Yes
- No
Comments
Are all of your vehicles, including recreational vehicles and watercraft, insured with this agency?
- Yes
- No
Comments
Have you recently purchased any additional automobiles, recreational vehicles, or watercraft?
- Yes
- No
Comments
Have you upgraded any of your vehicles with new equipment?
- Yes
- No
Comments
Do you drive any employer-sponsored vehicles?
- Yes
- No
Comments
Do you own any older vehicles that may be classic or collector cars?
- Yes
- No
Comments
Do you have any children who no longer live at home and can no longer be considered dependents?
- Yes
- No
Comments
Have you purchased any jewelry, electronics, or other valuables that you would like to add to your policy, such as:
- Jewelry
- Furs
- Guns
- Silverware
- Fine arts
- None
Comments
Are there any such items that you would like to change or remove from your policy?
- Yes
- No
Comments
Do you insure your personal possessions for their full replacement value?
- Yes
- No
Comments
Have you recently added or otherwise changed ownership of assets such as trusts, titles, or LLCs?
- Yes
- No
Comments
Are there any other insurance coverage issues you would like to discuss?
- Yes
- No
Comments
Do you want to leave money to loved ones in case of your or your spouses untimely death? ( In other words, Do you want Life insurance quotes? )
- Yes, I would like info on Life insurance options
- No, I am not interested at this time
Comments
Do you want us to cover your Business?
- Yes
- No
Life Insurance
What amount of benefit would you like to leave to your loved ones?
- $100,000
- $300,000
- $500,000
- $1,000,000
Comments
Business Insurance
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Total Number of Employees
Are there any business properties or pieces of equipment that you have recently acquired, leased, or sold?
- Yes
- No
Comments
Have you closed or opened any business locations?
- Yes
- No
Comments
Has your company building undergone any renovations, additions, or other significant changes?
- Yes
- No
Comments
Have you added, changed, or removed any company products?
- Yes
- No
Comments
Has your inventory level experienced any significant shifts or fluctuations?
- Yes
- No
Comments
Do you either purchase supplies from or sell your products to foreign countries?
- Yes
- No
Comments
Has the ownership structure of your business changed?
- Yes
- No
Comments
Has there been a 10% or greater change in your business's revenue in the last year?
- Yes
- No
Comments
Do 50% or more of your materials come from a single supplier?
- Yes
- No
Comments
Do 50% or more of your sales come from a single buyer?
- Yes
- No
Comments
Do any of your employees regularly work from home or from another state?
- Yes
- No
Comments
Do any of your employees regularly travel to other states or countries for business?
- Yes
- No
Comments
Do any of your employees travel for business in their personal vehicles?
- Yes
- No
Comments
Has your company leased, purchased, or sold any automobiles or other vehicles?
- Yes
- No
Comments
Do you require all vendors, subcontractors, and 1099 workers to provide certificates of insurance?
- Yes
- No
Comments
Are there any other insurance coverage issues you would like to discuss today?
- Yes
- No
Comments
Would you like us to quote or shop your insurance for you?
- Yes
- No
Comments
What types of insurance do you want us to quote or shop for you?
- Auto Insurance
- Home Insurance
- Landlord Insurance
- Tenant Insurance
- Business Insurance
- Life Insurance
Additonal comments or questions
Thank you for taking the time to complete this questionnaire. Please feel free to call us or email us with any questions or concerns. Chris Goebel and Jeff Burman (215) 465-9311 or email us. Thanks again!
Phone
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Customer Reviews

MT

I like the fact that since I've met you guys and have been a customer, I feel...Melanie T., Philadelphia, Pennsylvania

CB

Chris and his team are great. I have been with them for over 15 years and have...Chris B., Philadelphia, Pennsylvania

PC

If there was a 6th star Jeff Burman and Goebel insurance would get that. The...PAUL C., Philadelphia, Pennsylvania

5 stars!Saleena B., Philadelphia, Pennsylvania

...you were right there with a quick response with the information we needed...James T., Philadelphia, PA

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Goebel Insurance Agency, Inc.

2026 S 12th St
Philadelphia, Pennsylvania 19148

Phone: (215) 465-9311

Fax: (215) 465-9312

Mon-Fri: 9:00am-5:00pm
Sat-Sun: Closed

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Goebel Insurance Agency, Inc. Provides Car Insurance, Home Insurance, Pet Insurance, Business Insurance, and Commercial Auto Insurance to All of Pennsylvania, Including Philadelphia County, Bucks County, Montgomery County, Willow Grove, Jenkintown, and Southampton.

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Name	Driver / Non-Driver

Miles to work	Annual Miles	Vehicle

Annual Insurance Checklist

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