Commercial Five Star Insurance Questionnaire

Please review your renewal carefully!  The following questions are designed to assist both of us in this review.

( * indicates required information)

*Company Name:  
*Policy Number  
*E-mail address:  
Website Address:  
*Phone Number:  
*Contact Person:  
*Fax Number:  
   
Is the named insured and address listed on the policy correct? Yes No
If you have coverage on buildings, does the amount shown appear to be adequate to replace it? Yes No
After reviewing ALL of your policies, do you have adequate coverage? Yes No
Does the description of your operations properly include all that you do? Yes No
Have you deleted or added any operations since last year? Yes No
   
Would you like coverage or a quote for any of the following:
Earthquake
Sewer/Drain Backup
Pollution Liability
Flood Insurance
Income Protection
Umbrella/Excess Liability
Building Ordinance Coverage
Employment Practices Liability
Directors/Officers Liability
   
Do you use sub-contractors? Yes No
If yes, do you request Certificates of Insurance? Yes No
What is the total amount paid to ALL sub-contractors in the previous 12 months?
How many full-time (20+ hrs a week) employees do you have, on average, over the course of a year?
How may part-time (less than 20 hrs) employees do you have, on average, over the course of a year?
Of your part-time employees, how many are under 16 or over 65 years of age?
 
Are there any other coverages you want to discuss such as:
Life
Health
Long Term Care
Home
Auto
Bonds
   
Would you like to schedule an appointment with one of our agents? Yes No
Additional Comments
or questions:
 

I understand that NO changes to my policy or coverage are bound by submitting this online Renewal Request.
This Change request will be considered bound ONLY upon confirmation from my LIA agent.

I have read and agree with the above.
(Box must be checked before request is sent)
NOTE: This is to become part of your permanent insurance record with Lewis Insurance Associates
and will be shared with the company you are insured with.
 
   
 
 
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