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Business Insurance Checklist

Name
First Last
Date
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*
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?*
- Yes
- No
Please explain
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?*
- 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?
- Yes
- No
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?*
- Yes
- No
Please explain*
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?*
- 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, 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*

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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Specializing In Erie Insurance

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Customer Reviews

TM

Wendy and her staff are friendly, professional, and eager to please.tony m., Pennsylvania

CC

This is the best insurance broker for business and personal needs.Christman C., Pennsylvania

NW

Wendy and her team do fantastic work...Nate W., Pennsylvania

SM

Their rates are extremely competitive!Shelly M., Pennsylvania

So if you want a honest, ethical team...Alan D.

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Deibler Insurance Associates

26 Westminster Drive
Carlisle, Pennsylvania 17013

Phone: (717) 241-2775

Toll Free: (888) 241-2775

Fax: (717) 241-2575

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

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Local Erie Insurance Agent

Deibler Insurance Associates Provides Auto / Car Insurance, Home Insurance, Business / Commercial Insurance, 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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