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Date Format: MM slash DD slash YYYY
Since our last review – have you?
Had any change in ownership/partners?
Engaged in any new operations?
Purchased any new property, added additional locations?
Made any significant purchases for business property (furniture, fixtures, electronic equipment, mobile equipment)?
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?
Any changes to Additional Insureds, Certificate Holders, Loans, Mortgages?
Are any buildings/properties now vacant or unoccupied? Any change in occupancy?
If we insure your automobiles, have there been any changes in vehicles/trailers/drivers?
Check the business coverages below that you are concerned about or would like more information on:
Sewer/Drain Backup – Sump Pump Failure
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
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