Business and Contact Information

Business Name:*

Your Name:*

Contact Email Address:*

Contact Phone Number:*

Has the business mailing address changed?*
 Yes No

If yes, please provide new mailing address:

Please Check All That Apply
 Other changes not listed We have upgraded our building(s) and or fixtures We now lease out a portion of our location Our mortgagee or finance company information has changed Our ownership interest in our building has changed (e.g., rent vs. own) Our business has moved We have reduced business locations We have added business locations

If you checked any box above, please explain:


Please Check All That Apply:
 Have there been other changes to your business operations? Have you assumed any contractual obligations as a result of your business operations? Have you contracted out portions of your business operation? Have you changed the states where you do business?

If you checked any box above, please explain?

Business Personal Property

Have you added to or reduced your business personal property?*
 Yes No

Has there been a change to the location where business personal property is kept?*
 Yes No

Please describe any other changes to your business personal property:

Other Business Information:

How many employees do you now have?*

What are your sales projections for the next year?*

What is your projected inventory for next year?*

What is your projected payroll for the next year?*

Risk Management and Insurance Needs

Please check the boxes below for more information about protecting your business future:
 Business Continuation Bonds Group Benefits Crime Insurance Commercial Umbrella Commercial Liability Commercial Property Employment Practices Liability Directors and Officers Insurance Errors and Ommissions Insurance

Do you have any comments or are there any questions we can answer?