Business Account Review

General Information

Business Name *

First Name *

Gross Receipts?

Last Name *

Mailing Address *

City and State *

ZIP / Postal Code *

E-Mail Address *

Are you authorized to make changes on the business insurance policies? *

Yes
No

Has the name or entity type changed?

Yes
No

Please list owners / officers

Has the nature of your business changed?

Yes
No

Have you added any new job descriptions?

Do you hire sub contractors?

yes
no

Number of employees?

Property

If you own or are responsible for insuring the building, have you reviewed the replacement value?

Yes
No

Have you added any of the following security

Hold down the Ctrl Key to make multiple selections.

Is your operation's income dependent on someone else's property?

Have you renovated or improved your building at your expense?

Yes
No

If yes, what is the current replacement cost of the building?

I am aware of the co-insurance and settlement agreement in my policy

100% Coinsurance
90% Coinsurance
80% Coinsurance
Other Coinsurance - explained
Replacement Cost
Actual Cash Value
Agreed Value
Functional Replacement Cost

Who owns the building you occupy?

Are you responsible for maintaining the heating / AC or other building systems?

yes
no
need more information

Do you have a Cyber Liability or Data Breach Exposure?

yes
no
need more information

Have you reviewed your contents,stock,raw materials, work in progress and finished goods for updated values?

Yes
No

Square Footage of Building

Do you own any other property?

Have you signed or changed any leases?

Yes
No

Lease review needed?

Yes
No

Do you have a disaster plan?

Yes
No
Can I get more Information?

Link to Disaster Plan information

Disaster Plan Template

Would your business need Extra Expense coverage after a loss?

Yes
No
If Yes - we will quote

Would a loss of power on / off premises cause you a loss of income?

yes
no
need more information

Would your business lose income if it could not operate out of your current location?

Yes
no
need more information

Business Interuption Worksheet?

Business Interuption worksheet link

Have you reviewed your policy for coverage that includes

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Other Important Coverage to Consider

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Do you need to review Employee Dishonesty & Fraud Coverage?

yes
no
need more information

Liability

Current General Liability Limit

Per project aggregate?

Yes
No

Do you administer a 401k or Retirement Program?

Yes
No
I may be starting one soon

Auto

Current Auto Liability Limit

Have you added or deleted any vehicles?

Yes
No
n/a

Have you changed any drivers?

Yes
No
n/a

Have you hired any drivers you forgot to tell us about?

Yes
No
Not sure

Has you typical radius of driving changed?

Hold down the Ctrl Key to make multiple selections.

Would you like a copy of the drivers list we have on file?

Yes
No
Not Applicable

Would you like a copy of your fleet schedule to review?

Yes
No
n/a

Do you have a personal auto policy?

Yes
No
Drive Other Car needed?

Do you haul goods owned by others?

Yes
No

If so, what are you hauling?

Are you hauling any hazardous materials?

Yes
No
n/a

Equipment / Inland Marine / Floater

Have you reviewed your Equipment List for accuracy?

yes
no

Would you like a copy of your Equipment List for your review?

Notes about above

Do you lease, borrow or rent any equipment?

Yes
No

Notes about above

Do you let anyone rent, borrow or lease your equipment?

yes
no
need more information on this

Notes about above

Pollution Coverage review

I have coverage
I don't want coverage
I would like a quote on pollution coverage

Umbrella

Review Umbrella Policy

Don't have an umbrella
Want a quote
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
10,000,000
Other

Workers Compensation

What States have you worked in the last 12 months?

Workers Compensation - Have your payrolls changed more than 10%?

Yes
No

If Yes, would you like us to send you your most current payrolls on file by class code?

Yes
No
I will wait until my audit

Other

Would you like a quote on Employment Practices Liability

Yes
No
Already covered

Personal Auto, Home and Umbrella Policy review?

Yes
No
Maybe later on

Business Life Insurance

Yes - I have a policy or policies
No and I'm not interested
I may need some advice in that area at some point.

Are there any other changes / coverage you wish to review?

Electronically signed by

Electronic Signature *

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