BusinessInsuranceEvaluation2011

Business Insurance Needs Evaluation

Thank you for continuing your insurance coverage with us! At Kapnick Insurance Group, we recommend an annual review of all your insurance policies in order to keep your coverage up-to-date. The form below will help to make that review as quick and efficient as possible. Please take a moment to answer the questions and then click on submit. If you have any questions or request additional information, one of our Business Insurance Department professionals will be in touch. Please be sure to enter your contact information. Please note that optional coverage(s) may result in an increase in your insurance premium. If there is no response, the carrier will renew based upon the previous information on file.

Are there any changes to the named insured, or have you entered into any joint ventures, new corporations or partnerships in the past year? Yes No
If Yes - please explain:

Have there been any changes in operation or exposures this past year, including discontinuing products and/or services? Yes No
If Yes - please explain:

Do you feel your insurance amounts on your real and personal property are sufficient? Yes No
If No - please explain:

Do your or your employees use personal vehicles in the business (including running errands, picking up mail, etc.)? Yes No

Are you interested in higher property deductibles or higher limits of liability? Yes No

Have you added any additional vehicles or drivers? Yes No
If Yes - please explain:

Please note: 1) If you do not have a personal auto policy, please contact our office to discuss Broad Form Driver Other Car Coverage
2) If your vehicle has lettering and/or advertising, check with your personal auto agent to verify the vehicle is eligible to be covered on your personal policy.

Do you employ any Full or Part-Time Workers? Yes No
Any Temporary Employees used? Yes No
If yes, is a Certificate of Workers' Compensation Insurance obtained? Yes No

Michigan Law: Compulsory as to all Employers of 3 or more employees. Or, if less than 3, if 1 is employed for 35 hours per week for 13 weeks by the same employer.

Are there any other coverage additions or deletions not described above? Yes No
If Yes - please explain:

Check any of the following coverages for which you would like more information: Earthquake Flood Terrorism Mold

Company Name Contact Name Email Address
Phone Date

Please click here to submit your information

Thank you for your time! We're here to help - if you have any questions
or need assistance with this form, call 517.263.4656, option 3.