Contact Information
First Name*
Last Name*
Email Address*
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Coverages
The purpose of the following questions is to establish your desires in the event of a loss. Your policy may already provide coverage for some of these areas.
If an employee stole money from your business, would you want it paid back?
Yes
It's not something I am concerned about
Do you have any key employees that, in the event of their death, you would require time and money to replace?
Yes
It's not something I am concerned about
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?
I don't know
It's not something I am concerned about
Do you have computer or other electronic equipment you would want replaced in the event lightning hit your building?
Yes
No
If a loss caused your business to shut down for an extended period, would you need money to continue salaries or other business expenses?
Yes
It's not something I am concerned about
General Questions
Has your employee payroll changed?
Yes
No
How many employees do you currently have?
What are your gross receipts?
Have you added any new drivers?
Yes
No
Have you paid off any of your vehicles?
Yes
No
Have you had any change in ownership?
Yes
No
Have you purchased any new equipment?
Yes
No
Have you added a burglar alarm or other security devices?
Yes
No
If you had a chronic illness or disability that left you unable to care for yourself for an extended period of time, where would the money come from?
I don't know
It's not something I am concerned about
Other Policies
In order to properly protect your assets, it is important that we have complete information about your total account. Please list any policies, including personal auto, homeowners and group health, written with other agents.
Feedback
Has anyone in our office provided exceptional service over the last year. If yes, please tell us about it.
If we have provided value to you over the last year, we might also be able to help your friends and neighbors. Who would you suggest we contact?
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