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I Am…
- Individuals and Families
About
Support
Contact

Home > Business Insurance Checklist

Business Insurance Checklist

Business Insurance Checklist

* indicates required fields

Name

First Last

Date

MM slash DD slash YYYY

Phone

Email

Since our last review – have you?

Had any change in ownership/partners? *

Had any change in ownership/partners?

Yes

No

Please explain*

Engaged in any new operations?*

Engaged in any new operations?

Yes

No

Please explain*

Purchased any new property, added additional locations?*

Purchased any new property, added additional locations?

Yes

No

Please explain*

Any change of occupancy? Are any buildings/properties now vacant or unoccupied?*

Any change of occupancy? Are any buildings/properties now vacant or unoccupied?

Yes

No

Please list any upgrades, additions, improvements:*

Please list any updates made to heating/roof:*

Acquire/erect any detached structures?*

Acquire/erect any detached structures?

Yes

No

Please explain

Made any significant purchases for business property (furniture, fixtures, electronic equipment, mobile equipment)?*

Made any significant purchases for business property (furniture, fixtures, electronic equipment, mobile equipment)?

Yes

No

Please explain*

Do you have business property at another or additional locations?*

Do you have business property at another or additional locations?

Yes

No

Please explain*

Please provide us with updated annual gross sales/revenues:*

Please provide us with updated annual payroll (excluding owners):*

Total annual payroll of owners if INCLUDED in Work Comp Benefits:

Please indicate Total # Employees (FT/PT):*

Do any employees work from home or at another location?

Do any employees work from home or at another location?

Yes

No

Do any employees use their own car for use in your business?

Do any employees use their own car for use in your business?

Yes

No

Please provide us with the updated total cost of subcontractor costs (annual)

Have you entered into any new leases, or signed any new contracts?*

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?*

Any changes to Additional Insureds, Certificate Holders, Loans, Mortgages?

Yes

No

Please explain*

If we insure your automobiles, have there been any changes in vehicles/trailers/drivers?*

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

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, Bridges)

Employment Practices Liability (Discrimination, Harassment, Negligent Hiring/Firing, etc)

Cyber Liability/Data Breach Liability and Expense Coverage

Commercial Auto (if not currently with us)

Workers Compensation (if not currently with us)

Auto, Home, Life (if not currently with us)

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.

Best time to contact you:

Thank you for your continued business!

Please contact us if you have ANY Questions
Deibler Insurance Associates
(717) 241-2775

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Deibler Insurance Associates
26 Westminster Drive
Carlisle, Pennsylvania 17013

Phone: (717) 241-2775
Tollfree: (888) 241-2775
Fax: (717) 241-2575

Office Hours:

Mon-Fri: 8:30am-5:00pm
Sat-Sun: Closed

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Deibler Insurance Associates provides Auto, Home, Business, and Life Insurance to all of Pennsylvania, including Carlisle, Boiling Springs, Mechanicsburg, Newville, Camp Hill, Mount Holly Springs, New Cumberland, Shippensburg, Dillsburg, and Enola.

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