General Information

Business Name*

Person Completing this Checkup

Email*

Have you changed your company's form of ownership?

Yes

If yes, please describe.

Has your business changed owners or partners?

Yes

Do you now service products you manufacture?

Yes

Have you changed or expanded your products or services?

Yes

What are your new products or services?

Have you added new locations, closed locations, expanded into new states or outside of the United States?

Yes

If yes, which states or countries?

Have you closed or moved any locations?

Yes

If yes, what location have you closed or moved?

Have you changed the mailing address of your business?

Yes

If yes, what is your new mailing address?

Business Property

Please complete this section if you carry this coverage.

Do you own the building in which your business is located?

Yes

Does your current business personal property reflect the current cost to replace business property, inventory and any improvements & betterments?

Yes

Have you entered into any new purchase or lease agreements for business property?

Yes

If yes, please describe.

Business Liability

Please complete this section if you carry this coverage.

Has there been any increase/decrease in your company’s payroll or sales?

Yes

If yes, estimated change in payroll or sales

Have you entered into any new customer contracts?

Yes

If yes, please describe

Workers Compensation

Complete this section if you carry this coverage.

Have you had a change in the number of employees in the past 12 months?

Yes

Has there been any increase/decrease in your company’s payroll?

Yes

Do you have employees who work from home on a regular basis?

Yes

Do you use subcontractors, volunteers or interns?

Yes

Do you or your employees travel to other states or foreign countries?

Yes

If yes, please describe

Business Automobile

Please complete this section if you carry this coverage.

Have you added or eliminated vehicles used in your business operations?

Yes

If yes, please describe

Has the usage of vehicles covered by your policy changed?

Yes

Does anyone use your or your employees' personal vehicles in your business?

Yes

Do you feel that the liability limit on your policy is adequate?

Yes

Do you feel that any deductibles on your auto policy are appropriate?

Yes

But that's not all...

Below are additional coverage options that can help protect your business. Consider each statement and check the ones about which you'd like to hear more. Your E&K insurance counselor can assist you in determining which of these options are just right for your business.

I want to know more about insurance that will help...

Replace my lost business income if:

I need to suspend operations due to the direct physical loss of power, communication or water services. (Off Premises Utility Service Coverage).

The 3rd party I rely on for a large portion of my business income (e.g., supplier or manufacturer) is unable to provide inventory or products due to a covered loss at their location. (Dependent Properties Coverage).

One of my largest customers suspends operations due to a covered property loss. (Dependent Properties Coverage).

I use the internet to generate a portion of my income, and my website is vandalized (Electronic Vandalism Coverage).

After resuming operations following a covered loss, I do not reach the income level I had prior to the loss. (Extended Business Income Coverage).

Protect me if:

The sensitive personal information (e.g., Social Security number, debit/credit card information, medical records) I collect and/or store on my employees, customers and/or patients is lost or stolen. (Data Breach Coverage).

I am sued by one of my employees or third party for an employment-related claim, such as discrimination, harassment or wrongful termination. (Employment Practices Liability Coverage).

An error or omission is made in the administration of the employee benefits program available to my employees such as improper benefits advice or failing to enroll an employee when they’re eligible. (Employee Benefits Liability Coverage).

The computers, data and software used in my business need to be repaired or replaced due to a computer virus or power failure, for example. (Computers & Media Coverage).

I am sued because one of my employees was in an accident while running an errand for my business - such as picking up office supplies, or picking/dropping off mail at the post office. (Hired & Non-Owned Auto Coverage).

I am sued and my general or auto liability policies don’t fully cover the amount I am liable to pay. (Umbrella Coverage).