Business Owner Insurance Assessment Form
Please complete this assessment to help us understand your business insurance needs. Your responses will guide our recommendations.
What is your business type or industry?
*
Please Select
Retail
Hospitality
Professional Services
Manufacturing
Construction
Healthcare (non-sensitive)
Other
How many employees does your business have?
*
1-5
6-20
21-50
51-100
101+
Which types of business insurance do you currently have?
*
General Liability
Property Insurance
Workers’ Compensation
Professional Liability
Business Interruption
Cyber Insurance
None
Other
How would you rate your satisfaction with your current insurance coverage?
1
2
3
4
5
Please indicate your level of concern for the following risks:
*
Rows
Not Concerned
Somewhat Concerned
Very Concerned
Property Damage
1
2
3
Employee Injury
4
5
6
Customer Injury
7
8
9
Data Breach
10
11
12
Business Interruption
13
14
15
Have you filed any insurance claims in the past 3 years?
*
Yes
No
What are your top priorities when considering business insurance? (Select up to 3)
*
Comprehensive Coverage
Affordable Premiums
Quick Claims Process
Reputable Provider
Flexible Policy Options
Other
Are you interested in learning more about any of the following types of coverage?
Commercial Auto
Directors & Officers Liability
Employment Practices Liability
Product Liability
Umbrella/Excess Liability
None at this time
Do you anticipate any significant changes to your business in the next 12 months (e.g., expansion, new services, relocation)?
Yes
No
Please share any additional information or concerns about your business insurance needs.
Submit Assessment
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