Business Insurance Renewal Form

Business Name(Required)

Name(Required)

First Last

Business Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code

Email(Required)

Business Phone(Required)

Number of Owners(Required)

Have You Made Any Changes to the Operation of Your Business?(Required)

Do You Own The Building That You Occupy?(Required)

If You Own the Building, Is It Listed Under the Business Name?(Required)

If You Own the Building, Is It Listed Under the Business Name?

Have you made any updates to the roof, plumbing, wiring and heating systems to your commercial building the past year?(Required)

If so, please give us a brief description of what was updated:

Have you made any changes to the building, tenant improvements or betterments or increased your Business Personal Property? If yes, please contact our office(Required)

Have You Added or Updated Your Fire and/or Burglary Alarm System?(Required)

Is it Monitored? If yes, by whom?

What are your estimated Gross Receipts for the coming year? If you provide liquor what are your liquor receipts?

If you have employees, what is your estimated Annual Payroll, excluding Officers/Owners Payroll?

If you use subcontractors, what is the estimated annual costs?

Have you made any changes to your equipment or business property? Do we need to schedule any new items or increase coverage?(Required)

Have you made any changes to your business vehicles?(Required)

Have you added any new drivers?(Required)

Do we need to remove any lien or certificate holders?(Required)

Would you like us to quote any of the following Optional coverages? If yes, check all that apply(Required)

Higher Limits

Umbrella Policy

Coverage for Employment Practice Liability Insurance? (Sexual Harassment, Discrimination, Wrongful Termination)?

Personal Insurance (Home, Auto, Umbrella, Flood/Earthquake)

Cyber Liability

Term Life or Key Person Insurance

Disability Insurance

Would you like someone from our office to contact you regarding optional coverages?(Required)

Business Insurance Renewal Form

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