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Business Account Review


By reviewing the checklist and submitting it to R&A Insurance, I understand that each area has been reviewed by me. I further understand that if there is an exposure or coverage change, it is my responsibility notify R&A Insurance as soon as possible. 

A record of this completed review will be kept on file at R&A Insurance. 

By submitting this form, I declare that this review was completed to my satisfaction.   



General Information
Business Name
Required
First Name
Required
Gross Receipts?
Optional
Last Name
Required
Mailing Address
Required
City and State
Required
ZIP / Postal Code
Required
E-Mail Address
Required
Are you authorized to make changes on the business insurance policies?
Required

Has the name or entity type changed?
Optional

Please list owners / officers
Optional
Has the nature of your business changed?
Optional

Have you added any new job descriptions?
Optional
Do you hire sub contractors?
Optional

Number of employees?
Optional
Property
If you own or are responsible for insuring the building, have you reviewed the replacement value?
Optional

Have you added any of the following security
Optional


Hold down the Ctrl Key to make multiple selections.
Is your operation's income dependent on someone else's property?
Optional
Have you renovated or improved your building at your expense?
Optional

If yes, what is the current replacement cost of the building?
Optional
I am aware of the co-insurance and settlement agreement in my policy
Optional




Who owns the building you occupy?
Optional
Are you responsible for maintaining the heating / AC or other building systems?
Optional


Do you have a Cyber Liability or Data Breach Exposure?
Optional


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

Square Footage of Building
Optional
Do you own any other property?
Optional
Have you signed or changed any leases?
Optional

Lease review needed?
Optional

Do you have a disaster plan?
Optional


Link to Disaster Plan information
Optional
Disaster Plan Template
Would your business need Extra Expense coverage after a loss?
Optional


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


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


Business Interuption Worksheet?
Optional
Business Interuption worksheet link
Have you reviewed your policy for coverage that includes
Optional


Hold down the Ctrl Key to make multiple selections.
Other Important Coverage to Consider
Optional


Hold down the Ctrl Key to make multiple selections.
Do you need to review Employee Dishonesty & Fraud Coverage?
Optional


Liability
Current General Liability Limit
Optional
Per project aggregate?
Optional

Do you administer a 401k or Retirement Program?
Optional


Auto
Current Auto Liability Limit
Optional
Have you added or deleted any vehicles?
Optional


Have you changed any drivers?
Optional


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


Has you typical radius of driving changed?
Optional


Hold down the Ctrl Key to make multiple selections.
Would you like a copy of the drivers list we have on file?
Optional


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


Do you have a personal auto policy?
Optional


Do you haul goods owned by others?
Optional

If so, what are you hauling?
Optional
Are you hauling any hazardous materials?
Optional


Equipment / Inland Marine / Floater
Have you reviewed your Equipment List for accuracy?
Optional

Would you like a copy of your Equipment List for your review?
Optional
Notes about above
Optional
Do you lease, borrow or rent any equipment?
Optional

Notes about above
Optional
Do you let anyone rent, borrow or lease your equipment?
Optional


Notes about above
Optional
Pollution Coverage review
Optional


Umbrella
Review Umbrella Policy
Optional







Workers Compensation
What States have you worked in the last 12 months?
Optional
Workers Compensation - Have your payrolls changed more than 10%?
Optional

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


Other
Would you like a quote on Employment Practices Liability
Optional


Personal Auto, Home and Umbrella Policy review?
Optional


Business Life Insurance
Optional


Are there any other changes / coverage you wish to review?
Optional
Electronically signed by
Electronic Signature
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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