What is your first name?
What is your last name?
What is your company's name?
What is your preferred phone number?
What is your email address?
Customize This Form
A business risk evaluation entails completing the sections of this form that are applicable to your business. Note: You can deselect sections that are not applicable to your business to remove those questions from the form.
General Operations Review
This section will help identify changes to your business in order to identify new risks to discuss.
Has the legal name of your business changed?
What is the legal name of your business?
Has the mailing address of your business changed?
What is the new mailing address?
Has there been a change in the ownership structure of your business?
Please provide details about the ownership change below.
What is new with your business? (Select all that apply)
Please provide details about the new service(s) being offered.
Please provide details about the new product(s) being offered.
Please provide details about the new machinery/equipment.
Did your business purchased, rent or lease the new machinery/equipment?
Please enter the new state(s)/countries the business expanded to.
Please provide details about the new entity below.
What are your annual gross revenues this year?
Real Property Review
This section will help identify some common changes and updates to real property assets such as buildings, equipment and machinery.
Do you have a recent property appraisal showing the replacement cost of any building the business owns or is responsible for insuring?
Please upload a copy of the appraisal here, if possible.
What is the replacement cost of the building?
Does the business have more than one location?
Please enter the address of the additional location(s).
Have you added or removed any security, alarms, bars, or other property protection devices?
Please provide details about the security, alarms, bars or other property protection devices you added or removed.
Has the occupancy status of any building changed? (Ie. rented, vacant, under renovation, etc.)
Please enter the address of the building where the occupancy status has changed.
What is the occupancy status of this building?
Is there another building where the occupancy status has changed?
Please enter the address of the second building where the occupancy status has changed.
What is the occupancy status of the second building?
Do you utilize a property management company?
Does the business have any properties that we do not presently insure?
Did the business earn rental income this year?
What will the annual rental income be this year?
What is the antipated rental income for next year?
Does the business own any outdoor property? (Ex. Signs, generator, etc.)
Please select the types of outdoor property the business owns.
What is the approximate value of the sign(s)?
What is the approximate value of the lighting?
What is the approximate value of the generator?
What is the approximate value of the fencing?
What other type(s) of outdoor property does the business own?
Have any updates been done to any building the business owns?
Please select the areas that were updated.
What year was the electrical updated?
What year was the plumbing updated?
What year was the heating updated?
What year was the hurricane protection updated?
What year was the flood protection updated?
Do you have plans to do any new construction or remodeling?
Is any building the business owns susceptible to flooding?
Commercial Automobile Review
This section will help identify some common changes and updates to commercial automobile exposures.
Has the business purchased or leased any new automobiles?
Please enter the year, make, model and purchase type of the vehicle(s).
Have any new drivers been added?
Please enter information about the new driver(s).
Do you allow employees to use your personal vehicle for business use?
Business Staffing Review
This section will help identify risk exposures related to your staff.
How many employees do you have currently?
Has your employee payroll changed dramatically over the course of the last 12 months?
Please provide a brief description of the reason for the change in payroll. (Ie. New employees, etc.)
What is the projected payroll for the next 12 months?
Do you want to INCLUDE/EXCLUDE Partners, Officers, Owners, or Relatives from workers compensation coverage?
Please select the individuals you would like to EXCLUDE from workers compensation coverage.
Please select the individuals you would like to INCLUDE in workers compensation coverage.
Please enter information about the partner(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the partner(s) to be INCLUDED in workers compensation coverage.
Please enter information about the officer(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the officer(s) to be INCLUDED in workers compensation coverage.
Please enter information about the LLC Member(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the LLC Member(s) to be INCLUDED in workers compensation coverage.
Please enter information about the Owner(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the Owner(s) to be INCLUDED in workers compensation coverage.
Please enter information about the relative(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the relative(s) to be INCLUDED in workers compensation coverage.
Does your business utilize subcontractors?
What is the approximate percentage of work that is done by subcontractors? (Ex. 25%)
Is any work sublet without a certificate of insurance from the contractor?
What is the payroll for the subcontractors you do not collect certificates of insurance from?
Do you provide health insurance for your employee(s)?
Do you provide disability insurance for your employee(s)?
Coverage Assessment
This section will help uncover additional exposures to risk. Please keep in mind that coverage for certain areas may already be in place, but it is helpful to continue to assess these risks on an ongoing basis.
Does your business have machines or electronic equipment that may be susceptible to breaking down? (Ie. A/C, elevators, pumps, etc.)
Do your employees have access to cash or stock?
Please select the types of information your business collects. (Select all that apply)
Please select the different ways your business uses the internet. (Select all that apply)
What are the other ways your business uses the internet?
Have your business's total expenses changed in the last 12 months?
Do you expect your business to grow over the next 2 years?
Has your business's dependency on any one customer or supplier, including ones from overseas, changed in the past 12 months and/or is it likely to change moving forward?
Does your business ship or receive goods?
Does your business provide advice for a fee?
If a disgruntled employee sued the business for wrongful termination, sexual harassment or discrimination, would you want your policy to provide coverage?
Does the business have key employees that would require time and money to replace if they were to unexpectedly pass away?
Is income replacement coverage needed to protect key employees if they are unable to work due to a chronic illness or a disabling accident?
Have you reviewed the business's liability insurance program to ensure the adequacy of the limits?
Documents and Comments
Please use this field to upload any relevant insurance documents. (ie. Property appraisals, certificate requests, etc...)
Please enter any additional remarks or advise if there is anything else we can do for you in the space below.
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
