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Secure Commercial Renewal Review

 
Your Name:
First Last
Email Address:
Phone Number:
5 Digit Zip:

Operations

Have you had any address or location changes? Yes No
If "Yes", please explain:
Have there been any changes in ownership? Yes No
If "Yes", please explain:
Do you project any changes in payroll for the next policy term? Yes No
If "Yes", please explain any changes in payroll/employees.:
Do you project any changes in revenue for the policy term? Yes No
If "Yes", please explain:
Have there been any changes in your operations, or do you foresee any for the next policy term? Yes No
If "Yes", please explain:

Property

Have you purchased or sold any business property or equipment, or do you intend to for the next policy term? Yes No
If "Yes", please provide current estimated value of business personal property.
Have you made any building additions or improvements to your facility, or do you have any planned for the next policy term? Yes No
If "Yes", please explain and provide costs of any improvements or additions.:
Have you added or upgraded any safety/security devices? Yes No
If "Yes", please explain:

Auto

Have you purchased or sold any business/commercial vehicles during the current policy term? Yes No
If "Yes", and you would like to update this information, please provide year, make, model, and purchase price of any new vehicles, and date-of-sale for any sold vehicles:
Have there been any changes to your listed drivers during the current policy term? Yes No
If "Yes", and you would like to update this information, please provide the driver's name, date of birth, and driver's license number:

Miscellaneous Information

Would you like to schedule to a meeting to do a complete risk management review? Yes No
Would you recommend the MWI Insurance Brokers Team to your professional colleagues, friends, and family? Yes No
Please list anyone you feel would benefit from our services:
How satisfied are you with the service your are receiving from the MWI Insurance Brokers
Completely Satisfied Satisfied Neutral Dissatisfied Completely Dissatisfied
Please share any additional comments::
Agent Name (Optional):
Website Disclaimer - Review Carefully:

This information is not an offer to sell insurance. Insurance coverage cannot be bound or changed via submission of this online form/application, e-mail, voice mail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent. Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. All coverages are subject to the terms, conditions and exclusions of the actual policy issued. Not all policies or coverages are available in every state. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.