Commercial Insurance Review from PA Insurance Rates.com

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Questions?
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Agent!

E-mail Questions to: jrumer@rumergroup.com

Toll-Free: 1-888-81-RUMER
Phone: 1-215-918-1882
Fax: 1-215-918-2220

Office Located at:
1432 Easton Road, #3-I
Warrington, PA 18976

Commercial Insurance Coverage Review Request: One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your Name (First, Last)

Business Name

E-Mail (REQUIRED):

E-Mail (again to verify accuracy):

Phone (REQUIRED):

Your Policy Number (s): (If available)

Review Section
If an employee stole money from your business, would you want it paid back through insurance?	No Yes

Do you have any key employees that, in the event of their death, you would require time and money to replace them?	No Yes

If your company were to be sued for $1 Million more than your liability limits - where would you want the money to come from?

If a disgruntled employee sued you for an alleged wrongful termination, would you want your policy to include such coverage?	No Yes

Do you have computers, phones, or other electronic equipment you would want replaced in the event lightning hit your building?	No Yes

If a loss caused your business to shut down for an extended period of time, would you need money to continue salaries or other business expenses?	No Yes

Has your employee Payroll changed recently?	No Yes

How many Full Time Employees do you have?

How many Part Time Employees do you have?

What are your company's Gross Annual Receipts?	$

Has your company added any New Drivers?	No Yes (If Yes, List names below)

Have you paid off any of your vehicles?	No Yes (If Yes, List vehicles below)

Has your company had any change in ownership?	No Yes (If Yes, List new owners)

Has your company purchased any new equipment?	No Yes (If Yes, List equipment)

Has your company installed any burglar alarm or other security devices?	No Yes (If Yes, List Security)

If you had a chronic illness or disability that left you unable to care for yourself for an extended period of time, where would you want the money to come from?

May we offer you ANY of the following types of commercial insurance? (Check ALL that apply)	Workers Compensation Key Man Life Insurance Business Umbrella Coverage Disability Income Insurance Business Auto Crime Insurance Surety or Fidelity Bonds Other (List in Remarks below)

List any comments or special instructions here:

If we need further information, how should we contact you?	Fax E-Mail Regular Mail Please Call Me!

Thank you for filling out this form COMPLETELY!
We deem your data submitted as PRIVATE information. Every step has been taken to insure your privacy, security, and to release this information only to you. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Also, the insurance carriers reserve the right to issue coverage or not, and we cannot guarantee acceptance of a risk until approved by the company.
Yes, Please review my commercial insurance needs, and contact me if any changes or revisions may be needed!

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