Risk Review

Client Information
Name
First Name Last Name
Email
Email
Phone Number
Phone Number
Company Name
Company Name
Policy Number
Policy Number
What line(s) of coverage are you interested in discussing with our team?
- Private Risk Insurance
- Property and Casualty Insurance
- Health and Benefits
- Life Insurance
Please explain any changes with your health coverage or benefits packages.
Please explain any changes with your health coverage or benefits packages.
Please do not include any sensitive, private information in this area.
Home Address
Street Address Address Line 2 City State ZIP Code
Company Name
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Total Annual Sales
Total Annual Sales
Total Number of Employees
Total Number of Employees

Your Business Structure
Please think back over the last year when answering these questions.
Have you changed the ownership structure of your business?
- Yes
- No
Have you added new or changed your existing operations and/or products?
- Yes
- No
Have you begun to buy supplies or sell your products overseas?
- Yes
- No
Are you operating out of any new locations or have you closed locations?
- Yes
- No
Please explain any changes to your business structure.
Please explain any changes to your business structure.
Please do not include sensitive, private information in this area.

Your Personal Liability
Please think back over the last year when answering these questions.
Have you acquired, leased or sold a building, business property and/or equipment?
- Yes
- No
Have there been any improvements and/or significant alterations to your building?
- Yes
- No
Has your Inventory level changed significantly?
- Yes
- No
Have you purchased, leased or sold any Vehicles?
- Yes
- No
Please explain any changes to your personal liability.
Please explain any changes to your personal liability.
Please do not include sensitive, private information in this area.

Your Income Protection
Please think back over the last year when answering these questions.
Have your Businesses revenues changed by more than 10% since last year?
- Yes
- No
Do you rely on a single supplier for more than 50% of your materials?
- Yes
- No
Do you rely on a single buyer for more than 50% of your sales?
- Yes
- No
Please explain any changes to your income protection.
Please explain any changes to your income protection.
Please do not include sensitive, private information in this area.

Additional Protection
We're a full service agency providing solutions for personal, business, health and benefits and specialty Insurance needs for our clients.
Would you like to discuss any additional insurance protection with our firm?
- Yes
- No
Confirmation
Your initials
Your initials
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This field is for validation purposes and should be left unchanged.

Let’s ensure you have the right insurance in place.