Account Checkup

Account Check Up

Are your insurance needs up to date? If you received a recent renewal email, please compare the coverages highlighted to the ones that may be of interest or need to you. Upon completion of this survey we will gladly provide quotes on the coverages you requested.

In an effort to simplify your insurance policy renewal please complete this form so we can get to work on it right away.

What is the full legal name of your company?(Required)

Revenue

Operation Information

Locations

Location changes are the most neglected information.

Has your business added any new locations since the last renewal.(Required)

This applies to any new locations that we have not been made aware of.

New Locations(Required)

St Address

Zip Code

Description

Sq Feet

# Employees

Gross Sales

Please add details for each new location.

Additional Coverages

Which coverages, if any, are you interested in received a proposal for?(Required)

NONE

Benefit Packages (401K, Health, Dental, Vision, Payroll)

Commercial Auto (Auto insurance for vehicles your company owns or uses)

Crime Coverage/Employee Theft

Cyber Liability/Data Breach (Coverage for data hacks, malicious transfer, phishing attacks, network security)

Directors & Officers Coverage

Disability Insurance

Employment Practices (Protects your company against claims of wrongful termination, discrimination, sexual harassment, ADA Claims)

Errors & Omissions

Excess Liability (Increases your current liability limits)

Flood Insurance

Key Man Insurance (Insurance in case a key member of your team passes)

Life Insurance

Long Term Disability

Ocean Marine (Coverage for your products while in transit or storage)

Pollution/Environmental Insurance

Product Recall Coverage

Property in storage or transit (Things your company owns that are at a 3rd party location or in transit)

Property/Business Income Insurance (Things your company owns at your location/Lost Income)

Umbrella Policy

Workers Compensation (State mandated protection for your employees)

With some additional information, we'll gladly provide you a no-obligation quote for any of the following.

Benefit Packages

Which benefit s are you interested in?(Required)

Aflac

Dental Insurance

Group Health Insurance

Payroll Services

Vision Insurance

401K, IRAs & Retirement

529 College Savings Programs

Excess Liability / Umbrella

General Liability, Workers Comp and Commercial Auto Insurance are required for a Commercial Umbrella Policy. Otherwise, an excess liability policy will be quoted

How much additional liability are you seeking?(Required)

Cyber Liability / Data Breach

Approximately how many individual records does your company and/or website store?(Required)

Total number of records for unique individuals

Please indicate what electronic safeguards your operation keep in place(Required)

None Of These

Up-to-date, active firewall technology

Up-to-date, active anti-virus software on all computers, networks, and mobile devices

A process in place to regularly download and install patches

Backup and recovery procedures in place for all important business and customer data

An incident response plan to respond to a network intrusion

A disaster recovery plan, business continuity plan, or equivalent to respond to a computer system disruption

Controls to ensure the content of media communications and websites are lawful

Procedures in place which require service providers with access to your systems or confidential information to demonstrate adequate network security controls

Multi-factor authentication for remote access to email and other systems and programs that contain private or sensitive data in bulk

Are you currently compliant with Payment Card Industry Data Security Standards (PCIDSS)?(Required)

Yes

N/A

Is your operation HIPAA compliant(Required)

Yes

N/A

Cyber/Data Breach Limit You 'd like a quote for?(Required)

Cyber/Data Breach Deductible(Required)

Property Insurance

Property Coverages

St Address

Zip Code

Sq Feet

# of employees

Construction?

Burglar Alarm

Fire Alarm

Sprinklers

Revenue at this Location

Property Coverage

Business Interruption

Please complete a row for each location

Ocean Marine

What is the total annual value of merchandise you are importing?(Required)

Import Details(Required)

Country of Origin

Country of Destination

Product Type

Annual Shipped Value

Average Shipment Value

Max Shipment Value

Shipments Per Year

Transport Type

Warehousing Details(Required)

St Address

Zip Code

Product Type

Average Value at This Location

Max Value at This Location

Location Type

$ Coverage Requested Here

Enter Details for each location you have inventory stored at

Product Recall

How much recall coverage are you seeking?(Required)

Do you currently have a written product recall plan in place?(Required)

Please upload a copy of your formal recall policy

Accepted file types: pdf, doc, docx, Max. file size: 100 MB.

Workers Compensation

Payroll Breakdown - Prior Year

Payroll At Your Premises - Prior Year(Required)

Clerical, Managerial

Manufacturing

Sales

Warehouse

Payroll Breakdown - Upcoming Year

Payroll At Your Premises - Upcoming Year(Required)

Clerical, Managerial

Manufacturing

Sales

Warehouse

Disability Insurance

Owners/Managers

Full Name

Gender

Included?

How Many Male Employees Do You Have?(Required)

How Many Female Employees Do You Have?(Required)

What Benefit Level Would You Like?(Required)

Statutory DBL pays 50% of salary to a maximum benefit of $175/week. 1.5-times DBL pays 50% of salary up to $255/week. 2-times DBL pays 50% of salary up to $340/week. 3 times DBL pays 50% of salary up to $510/week. 4-times DBL pays 50% of salary up to $680/week. 5-times DBL pays 50% of salary up to $850/week.

Would you like to Included Accidental Death & Dismemberment?(Required)

Yes $50,000 (Mo. Rate Approx $1.00)

Yes $100,000 (Mo. Rate Approx $2.00)

Provides coverage for accidental death and dismemberment 24/7 2 death benefit levels are available $50,000 and $100,000 The benefit amount for covered dismemberments is 50% of the death benefit

Would you like to Include an In-hospital Rider(Required)

Yes

The In-hospital Rider pays an additional maximum of $170/week while an employee is hospital-confined - even during the 7-day waiting period for regular (underlying) DBL After the 7-day waiting period, the in-hospital benefit continues for as long as the employee is hospitalized, and is in addition to the underlying DBL benefit Duration for in-hospital benefit is tied to the mandated DBL maximum of 26 weeks of consecutive disability

Would you like to Include an Employer & Employee Assistance Program(Required)

Yes

Resources and advice for your business are just a phone call away! Consultants available 24/7 to help: - Improve employee performance - Guide you through basic tax/legal questions - Reduce absenteeism - Resolve conflicts - Manage employee stress, substance abuse, depression

Additional Information

Please use this space to provide any additional information that you think may be relevant to this application

Final Details

What is your full name?(Required)

What is your position in the company?(Required)

What Email address can we contact you at?(Required)

What phone number can you be reached at?(Required)

Account Checkup

Account Check Up

In an effort to simplify your insurance policy renewal please complete this form so we can get to work on it right away.

Revenue

Operation Information

Locations

Additional Coverages

Benefit Packages

Excess Liability / Umbrella

Cyber Liability / Data Breach

Property Insurance

Ocean Marine

Product Recall

Workers Compensation

Payroll Breakdown - Prior Year

Payroll Breakdown - Upcoming Year

Disability Insurance

Additional Information

Final Details

Section Break

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