Your Business Account Review Form

Name of Person Completing this Form *

Business Name *

Best Phone Number:

Please enter a valid phone number.

Email

example@example.com

How many employees do you currently have?

Full Time:

Part Time:

2. What is your current gross annual employee payroll (excluding Owners)?

3. What are your gross annual receipts (sales) for your business operations?

4. Are there any new drivers (If we insure your business auto)?

YESNON/A

. Have you paid off any of your vehicles?

YESNON/A

6. Have you had any change in ownership?NO

YESNO

If YES above, please provide details:

7. Have you purcased any new property or business equipment?

YESNO

7. Have you purchased any new property or business equipment?

YESNO

Your policy may or may not already provide coverage for some of these areas. We want to make sure you are always properly protected.

1. If an employee stole money from your business, would you want it paid back?

YESNO, it's not something I'm concerned about.

2. Do you have any key employees that, in the event of their death, you would require time and money to replace?

YESNO, it's not something that I'm concerned about.

3. If your company were to be sued for $1,000,000 more than your business liability limits, where would you want the money to come from?

My insurance policy.I have it taken care of.It's not something I'm concerned about.I don't know.

4. If a disgruntled employee sued you for an alleged wrongful termination, would you want your policy to cover it?

YESNO

5. Cyber liability insurance has become a significant exposure for many businesses. Would you like to discuss adding or upgrading this coverage for your business?

YESNO

6. If you have had any claims in the past 5 years, were they all handled to your complete satisfaction?

YESNOI have not had any claims.

7. Is there anything additional you would like us to know about that might affect your insurance program?

Please be advised that no updates or changes can be made to any of your insurance policies until you authorize one of our agents to process any policy changes.

Thank you, for your time!

Your Business Insurance Account Review