CL Renewal Survey in San Antonio, TX | My Insurance Group

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 paperwork

Policy Type(Required)

Please check the policy types you are completing the renewal survey for.

General Liability

Commercial Auto

Worker's Comp

Professional Liability

Excess Liability/Umbrella

Employment Practice Liability

Equipment/Installation Floater

Directors & Office Liability

Other

Have there been any changes to your operations or ownership?(Required)

Yes

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

Please describe any claims or incident(s) that could lead to a potential claim including date of the incident:(Required)

Please include at least the following: Date, time, location and details of the loss/claim.

Has your business moved?(Required)

Yes

Please enter your new business address:(Required)

Street Address City 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?

Please provide the number of all employees, including: fulltime, part-time, W2 and uninsured subcontractors which you have direct supervision of their work, hours and job location. DO NOT include owners/partners.

Please estimate your payroll total for all employees for the next 12 months:(Required)

Do not include owner/partner payroll

Do you subcontract *any* work?(Required)

Yes

Please estimate the total cost of subcontractors for the next 12 months:(Required)

Estimate the cost of subcontractors including labor and materials

Do your subcontractors carry their own insurance with matching limits of liability, hold harmless clause and you as an additional insured on their policy?(Required)

Yes

Do you generally use the same subcontractors?(Required)

Yes

Have there been any changes to drivers and/or vehicles?(Required)

Yes

Are all vehicles listed on the policy titled in the business name?(Required)

Yes

Please identify the vehicles not titled to the business and how the vehicle is titled:(Required)

Example: 2022 GMC Sierra - titled to: John Smith, Owner

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

Cyber Liability

Employment Practice Liability

Equipment/Installation Floater

Directors & Office Liability

Other

Additional Information

Please provide us with any additional information that you feel will help us with your renewal application.

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.

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