Blue Ridge Insurance & Title Agency
  Phone: 540.955.1178 (540)955-1178   Email Us
Blue Ridge Insurance & Title Agency

Independent Insurance Agent
Independent Insurance Agent

Trusted Choice

Blue Ridge Insurance & Title Agency

Auto Policy Renewal Protection Checklist

Please complete the form below so that we may assist you in maintaining the proper coverage at the best rate on your automobile policy. One of our representatives will contact you shortly after receiving this notification.

Policy Holder Information
Please be sure to supply your phone number and email address
so that we may contact you after receiving this notification.
Form Completed By:
Phone #: Work     Home   Cell

Renewal Protection Checklist
Please indicate
Yes, No, or Insured (meaning you already have the coverage)
Yes No Insured
Do we insure ALL the vehicles you own? 
If not, who does?  
Can we provide you with a FREE Instant Savings Comparison Proposal?: Yes 
Are you interested in adding or increasing your Accident & Death Benefit Limits?:
Are any vehicles NOT registered or titled in you and/or your spouse's name? 
If so which vehicle and whose name is on the title?:  
Has any vehicle been customized or altered?:
Are you interested in obtaining information on a $1,000,000 umbrella liability insurance policy that would protect you in the event of a catastrophic accident?:
If you own pickup or van, does it have customized equipment, camper, or shell?:
Do you own a mini-bike, moped, motorized scooter or motorcycle?:
Do you own any ATVs, boats, snowmobiles, motor homes or trailers?:
Do you have any students away at college? 
If so do they live in a dorm?: Yes 
Have you (or spouse) changed jobs in the last 12 months? 
If so, how far are you (or spouse) driving one way to new job and in which car?:  
If you don't already have "Rental Car Coverage", would you like to have a rental car provided for you if you get in an auto accident?:
Is there anyone that lives in your house that is not listed on your auto policy? 
If so what is their name, birthday and relation to you?:  
Do you have a teenager that is going to be getting a permit in the next year? 
If so, name and birthday?:  
Would you like to be reimbursed if you have to have your car towed?:
Are any of the cars on your policy used for any type of business use? 
If so how are they used?:  

Additional Comments
Please give any additional comments you feel appropriate for this checklist.

Please click on the "Submit Form" button to send your service request.
One of our representatives will respond to your submission as soon as possible.


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Blue Ridge Insurance & Title Agency Blue Ridge Insurance & Title Agency
Blue Ridge Insurance & Title Agency
110 S. Church Street
Berryville, Virginia 22611
Blue Ridge Insurance & Title Agency
Blue Ridge Insurance & Title Agency

Important Note:   This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states.
For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.
Blue Ridge Insurance & Title Agency
Blue Ridge Insurance & Title Agency
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