| Business Insurance

Business Name

Do you wish to make, or do circumstances require any changes to your current liability limits or coverage amounts?

Yes
No

Have you made any improvements or renovations to your buildings or added any structures since you last reviewed the coverage amounts on your policy?

Yes
No

Does your building/premises have:

Smoke Detectors
Dead Bolt Locks
Fire Extinguishers
Alarm System

Have you added, changed, or deleted any security systems, safes, or sprinkler system?

Yes
No

Any changes or additional equipment, signs, computer equipment, tools purchased?

Yes
No

Has there been any change in your business; such as:

New products sold or services provided?
Changes to existing products or services offered?
Changes in operations or types of work performed?

Are you regularly in possession of other people’s property? (i.e., for repair or maintenance)

Yes
No

Do you or any employee carry company money off site?

Yes
No

Are all owned or leased vehicles listed on your policy?

Yes
No

Do you work, maintain or operate a business, or keep samples for your business at any other location not listed on your policy?

Yes
No

Would you like information on wind mitigation credits?

Yes
No

Your property coverage may not provide coverage for ordinance or law. Do you want a quote for this very valuable coverage?

Yes
No

If you do not have a workers’ compensation policy, would you like a quote?

Yes
No

Would you be interested in a quote for Employment Practices Liability Insurance? (Wrongful Termination, Discrimination, Sexual Harassment, etc.)

Yes
No

Have there been any changes in:

Payroll
Sales Receipts
Space Occupied

Do you own any additional property, vacant land, or rent or sublet any portion of your building to others?

Yes
No

Does your office have any recreational facilities?

Yes
No

Do you obtain certificates of insurance from all subcontractors?

Yes
No

Your business policy DOES NOT provide flood insurance. Would you be interested in a flood insurance cost quotation?

Yes
No

Would you be interested in a quotation for Life, Retirement, Group Health or Disability insurance?

Yes
No

Please describe all your operations, products, or services:

Insured’s Signature

Date

Title

Phone Number

Email Address

Address

Street Address Address Line 2 City State ZIP Code