CL Renewal Survey Step 1 of 6 16% Name(Required) First Last Please provide the contact information for the submitter of this form.Email(Required) Mobile Number(Required) Policyholder Name(Required) As shown on the policy paperworkPolicy Type(Required) General Liability Commercial Auto Worker's Comp Professional Liability Excess Liability/Umbrella Employment Practice Liability Equipment/Installation Floater Directors & Office Liability Other Please check the policy types you are completing the renewal survey for.Have there been any changes to your operations or ownership?(Required) Yes No Have you filed any claims (paid or unpaid by the carrier) or are you aware of a situation that could lead to a claim during the last 12 months of coverage?(Required) Yes No Please describe any claims or incident(s) that could lead to a potential claim including date of the incident:(Required) Has your business moved?(Required) Yes No Please enter your new business address:(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please estimate your GROSS sales/revenue for the next 12 months:(Required)Gross Sales/Revenue = total of sales before *any* and all expenses, taxes, etc.How many employees do you have?(Required)Please provide the number of all employees, including: fulltime, part-time, W2 and 1099 employees which you have direct supervision of their work, hours and job location.Please estimate your payroll total for all employees for the next 12 months:(Required)Do not include owner's payrollDo you subcontract *any* work?(Required) Yes No Have there been any changes to drivers and/or vehicles?(Required) Yes No Please estimate the total cost of subcontractors for the next 12 months:(Required)Estimate the cost of subcontractors including labor and materials Are you interested in rounding out your business's insurance protection with any additional lines of business?If YES, please check any boxes to let us know which additional coverages you are interested in learning about. General Liability Commercial Auto Worker's Comp Professional Liability Excess Liability/Umbrella Employment Practice Liability Equipment/Installation Floater Directors & Office Liability Other Consent(Required) I understand and agree to the following:In assisting you with your insurance needs we are dependent on the information provided to us by you. If any of these area or others that need to be evaluated, please bring them to our attention prior to renewing your policy. Should any of your business operations or exposures change, it is your responsibility to let us know promptly so coverage can be adjusted accordingly. Submitting this renewal survey DOES NOT constitute confirmation of coverage of a new or revised insurance coverage. Please allow up to 1 business for an agency representative to contact you. My Insurance Group is committed to respecting your privacy and communication preferences. So that we may remain compliant with state and federal regulations, we need your expressed permission to communicate with you through phone, text and email as needed. You may opt-out of all future communication at any time by making your preferences known to us.CAPTCHA
