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Business Insurance Checklist
Business Insurance Checklist
Name
First
Last
Date
Date Format: MM slash DD slash YYYY
Phone
Email
Since our last review – have you?
Had any change in ownership/partners?
Yes
No
Please explain
*
Engaged in any new operations?
Yes
No
Please explain
*
Purchased any new property, added additional locations?
Yes
No
Please explain
*
Made any significant purchases for business property (furniture, fixtures, electronic equipment, mobile equipment)?
Yes
No
Please explain
*
Please provide us with updated annual gross sales/revenues:
Please provide us with updated annual payroll:
Please indicated Total # Employees:
Please provide us with the updated total cost of subcontractor costs (annual)
Have you entered into any new leases, or signed any new contracts?
Yes
No
Please explain
*
Any changes to Additional Insureds, Certificate Holders, Loans, Mortgages?
Yes
No
Please explain
*
Are any buildings/properties now vacant or unoccupied? Any change in occupancy?
Yes
No
Please explain
*
If we insure your automobiles, have there been any changes in vehicles/trailers/drivers?
Yes
No
Please explain
*
Check the business coverages below that you are concerned about or would like more information on:
Business Coverages
Sewer/Drain Backup – Sump Pump Failure
Earthquake
Flood/Surface Water Coverage Extended Income Protection (Loss of Income, Loss of Rental Income)
Increased Coverage for Theft of Cash, on/off Premises, Within a Bank, or Computer Fraud
Employee Dishonesty
Property Off Premises (Tools, Materials, Equipment, Supplies, etc)
Tools Off Premises
Equipment Off Premises
Mobile Equipment Coverage
Mobile Trailers/Job Trailers
Off Premises Power Failure Coverage (Damage to Building and/or Income Protection)
Property In Transit/Property Being Shipped/Cargo
Business Catastrophe Liability/Umbrella Liability
ERISA Bond to Cover Pension Plans
Employee Benefit Programs (Group Health, Life, Disability, Accident)
Risk Control/Loss Control Services (Provided Free of Charge)
Fleet Safety, Work Comp Safety Committee, Mock OSHA Inspection, Building Safety
Building Upgrades Required by Ordinance Following a Claim
Miscellaneous Property (Swimming Pools, Fences, Walks, Tennis Courts, Gas Pumps, Playground Equipment, Parking Garages)
Employment Practices Liability (Discrimination, Harassment, Negligent Hiring/Firing, etc)
Cyber Liability/Data Breach Liability and Expense Coverage
Approximate Amount of Pension Plan Value (Currently)
How can we better serve you? / additional comments / questions
Helpful links for our customers – Free of Charge:
Employer Human Resource & Admin Resources
Disaster Management Resources
Data Breach Resources*
*only for those customers that have data breach on their policy
Thank you for taking the time to update us on your coverage needs.
Please let us know a good time to meet and personally review your renewal coverages.
Thank you for your continued business!
Please contact us if you have ANY Questions
Deibler Insurance Associates
(717) 241-2775