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Fort Lauderdale Policy Review
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Fort Lauderdale Policy Review
Fort Lauderdale Policy Review
Client Information
Your Name
*
Your Name
First
First
Last
Last
Your Phone Number
*
Your Email
*
What insurance do you currently have with us?
Personal Insurance
Business Insurance
Home Address
*
Home Address
Home Address
Home Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Company Address
*
Company Address
Company Address
Company Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Total Annual Sales
*
Total Number of Employees
*
Your Home(s)
Have you remodeled or made any major updates to an existing home(s)?
*
Yes
No
(New roof, furnace, or electrical system)
Have you added a home security system?
*
Yes
No
Have you started a home-based business?
*
Yes
No
Have you purchased a secondary residence, including a condo or timeshare?
*
Yes
No
Have you started participating as a service provider in the home sharing economy?
*
Yes
No
(Airbnb, VRBO)
Please explain any changes to your home.
Your Automobiles and other “Vehicles”
Please think back over the last year when answering these questions.
Have you added an automobile, watercraft, or recreational vehicle?
*
Yes
No
Have you added any new drivers?
*
Yes
No
Have you added a vehicle provided by an employer?
*
Yes
No
Have you had a child leave home to attend school or no longer considered a dependent?
*
Yes
No
Have you started participating as a service provider in the ridesharing economy?
*
Yes
No
(Uber, Lyft, Sidecar)
Please explain any changes to your automobiles and "other" vehicles.
Your Other Life Events
Please think back over the last year when answering these questions.
Have you added or changed ownership of any assets including titles, trusts or LLCs?
*
Yes
No
Have you hired domestic help, nanny or housekeeper, either full or part-time?
*
Yes
No
Have you purchased jewelry, art or other valuables that need to be added? Are there items that need to be changed or deleted?
*
Yes
No
Have you had a significant change in net worth?
*
Yes
No
Have you accepted a position on a board(s) of a profit or nonprofit organization(s)?
*
Yes
No
Please explain any changes.
Your Business Structure
Have you changed the ownership structure of your business?
*
Yes
No
Have you added new or changed your existing operations and/or products?
*
Yes
No
Have you begun to buy supplies or sell your products overseas?
*
Yes
No
Are you operating out of any new locations or have you closed locations?
*
Yes
No
Please explain any changes to your business structure.
Additional Protection
We're a full service agency providing solutions for personal, business, employee benefits and specialty Insurance needs for our clients.
Would you like to discuss any additional insurance protection with our firm?
Yes
No
Signature Confirmation
Clear
Coverage will not be bound or changed until confirmed by a licensed agent.
Your Personal Liability
Please think back over the last year when answering these questions.
Have you acquired, leased or sold a building, business property and/or equipment?
*
Yes
No
Checkboxes
Option 1
Option 2
Have there been any improvements and/or significant alterations to your building?
*
Yes
No
Has your Inventory level changed significantly?
*
Yes
No
Have you purchased, leased or sold any Vehicles?
*
Yes
No
Please explain any changes to your personal liability.
Your Income Protection
Please think back over the last year when answering these questions.
Have your Businesses revenues changed by more than 10% since last year?
*
Yes
No
Do you rely on a single supplier for more than 50% of your materials?
*
Yes
No
Do you rely on a single buyer for more than 50% of your sales?
*
Yes
No
Please explain any changes to your income protection.
Your Employees & Professional Liability Exposure
Please think back over the last year when answering these questions.
Do you have employees that regularly travel out of state or overseas for business?
*
Yes
No
Checkboxes
Option 1
Option 2
Do any employees use their own personal cars for business purposes?
*
Yes
No
Do any Employees work outside your home state or work from their home regularly?
*
Yes
No
Do you obtain Certificate of Insurance from all subcontractors, vendors and 1099 workers?
*
Yes
No
Are any of the owners a member of any board of directors whether for profit or not?
*
Yes
No
Please explain any changes to your employees and personal liability exposure.
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