Policy Review

Step 1 of 9

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Client Information

First Name

Last Name

Email*

Phone Number

What insurance do you currently have with us?

Personal Insurance

Business Insurance

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company Name*

Company Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Home(s)

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

Have you remodeled or made any major updates to an existing home(s)?*

Yes

(New roof, furnace, or electrical system)

Have you added a home security system?*

Yes

Have you started a home-based business?*

Yes

Have you purchased a secondary residence, including a condo or timeshare?*

Yes

Have you started participating as a service provider in the home sharing economy?*

Yes

(Airbnb, VRBO)

Please explain any changes to your home.

Your Automobiles and other “Vehicles”

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

Have you added an automobile, watercraft, or recreational vehicle?*

Yes

Have you added any new drivers?*

Yes

Have you added a vehicle provided by an employer?*

Yes

Have you had a child leave home to attend school or no longer considered a dependent?*

Yes

Have you started participating as a service provider in the ridesharing economy?*

Yes

(Uber, Lyft, Sidecar)

Please explain any changes to your automobiles and "other" vehicles.

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

Your Other Life Events

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

Have you added or changed ownership of any assets including titles, trusts or LLCs?*

Yes

Have you hired domestic help, nanny or housekeeper, either full or part-time?*

Yes

Have you purchased jewelry, art or other valuables that need to be added? Are there items that need to be changed or deleted?*

Yes

Have you had a significant change in net worth?*

Yes

Have you accepted a position on a board(s) of a profit or nonprofit organization(s)?*

Yes

Please explain any changes.

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

Your Business Structure

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

Have you changed the ownership structure of your business?*

Yes

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

Yes

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

Yes

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

Yes

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

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

Yes

Has your Inventory level changed significantly?*

Yes

Have you purchased, leased or sold any Vehicles?*

Yes

Please explain any changes to your personal liability.

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

Your Income Coverage

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

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

Yes

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

Yes

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

Yes

Please explain any changes to your income Coverage.

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

Your Employees & Professional Liability Exposure

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

Do you have employees that regularly travel out of state or overseas for business?*

Yes

Do any employees use their own personal cars for business purposes?*

Yes

Do any Employees work outside your home state or work from their home regularly?*

Yes

Do you obtain Certificate of Insurance from all subcontractors, vendors and 1099 workers?*

Yes

Are any of the owners a member of any board of directors whether for profit or not?*

Yes

Please explain any changes to your employees and personal liability exposure.

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

Additional Coverage

Would you like to discuss any additional insurance Coverage with us?*

Yes

Confirmation

Your Initials

Policy ReviewLet’s ensure you have the right insurance in place.

It’s time to review your insurance.

Policy Review

Policy Review

Your Home(s)

Your Automobiles and other “Vehicles”

Your Other Life Events

Your Business Structure

Your Personal Liability

Your Income Coverage

Your Employees & Professional Liability Exposure