Policy Review

First Name

Last Name

Email

Phone/Mobile

What insurance do you currently have with us?

Personal Insurance

Business Insurance

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Total Annual Sales

Total Number of Employees

Your Business Structure

Please think back over the last year when answering these questions.

Have you changed the ownership structure of your business?

Yes

No

Have you added new or changed your existing operations and/or products?

Yes

No

Have you begun to buy supplies or sell your products overseas?

Yes

No

Are you operating out of any new locations or have you closed locations?

Yes

No

(Airbnb, VRBO)

Please Explain any changes to your business structure.

Please do not include sensitive, private information in this area.

Your Personal Liability

Please think back over the last year when answering these questions.

Have you acquired, leased or sold a building, business property and/or equipment?

Yes

No

Have there been any improvements and/or significant alterations to your building?

Yes

No

Has your Inventory level changed significantly?

Yes

No

Have you purchased, leased or sold any Vehicles?

Yes

No

(Uber, Lyft, Sidecar)

Please explain any changes to your personal liability.

Please do not include sensitive, private information in this area.

Your Income Protection

Please think back over the last year when answering these questions.

Have your Businesses revenues changed by more than 10% since last year?

Yes

No

Do you rely on a single supplier for more than 50% of your materials?

Yes

No

Do you rely on a single buyer for more than 50% of your sales?

Yes

No

Please explain any changes to your income protection.

Please do not include sensitive, private information in this area.

Additional Protection

Would you like to discuss any additional insurance protection with us?

Yes

No

Confirmation

Your Initials

Let’s ensure you have the right insurance in place.

It’s time to review your insurance.

Your Business Structure

Your Home(s)

Your Personal Liability

Your Income Protection

Your Automobiles and other "Vehicles"

Your Employees & Professional Liability Exposure

Your Other Life Events

Additional Protection

Confirmation

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