Commercial Insurance Review Commercial Insurance Review In an effort to verify the insurance coverage your business has through our agency, complete the following information so we can update your policies. Business Name*Provide your current business name.Phone #Fax #Email FEIN #For Corporations, Non-Profits or LLCs.SSN #For Sole Proprietors & Partner EntitiesHas Mailing Address Changed? No Yes New Mailing AddressAuthorized PersonnelList all individuals you want authorized to speak with our agency.Have you had any changes to the business this past year?*Changes include number of employees, payroll, sales, ownership, entity, mailing address, physical address, operations, value in business personal property, vehicles, drivers. No Yes Employee & Owner InfomrationDescription of OperationsProvide a brief description of your operations.Number of Full Time EmployeesSelect01234567891011+Number of Part Time EmployeesSelect01234567891011+Estimated Employee Annual Gross PayrollExclude owner's payroll.Owner/Officer Estimated Annual Gross PayrollInclude all owners.Total Estimated Annual Gross Payroll (All)Owners NamesList all owners.Do owners want to be included or excluded from Workers' Compensation?IncludeExcludeCompany InformationAnnual Gross Domestic SalesAnnual Gross Foreign SalesAnnual Cost of Sub-Contractors (1099s)Has Ownership Changed? No Yes New Owner InformationHas Entity Changed? No Yes New Entity NameNew FEIN #Has the Operations Changed? No Yes New OperationsProvide a brief description of the new operations.Property CoverageContractor's Equipment Value(If Applicable)Contractor's Hand Tools Value(If Applicable)Rented/Leased Equipment Value(If Applicable)Materials to Be Installed Value(If Applicable)Business Personal Property/Contents Value(If Applicable)Has There Been any Changes to Your Building?If you lease/rent your building, make "N/A". No Yes N/A Building ChangesProvide a brief description of changes.New Building ValueDo You Need to Add Another Location? No Yes New Location Address 1Do You Own or Lease/Rent This Location? Own Lease Vehicle Information(If Applicable)Remove VehiclesUse this section to remove vehicles.YearMakeModelVIN # Add VehiclesUse this section to add vehicles.YearMakeModelVIN #Liability Only?Full Coverage? Comprehensive DeductibleChoose an option if you've entered full coverage.Select$100$250$500$1,000$2,500Collision DeductibleChoose an option if you've entered full coverage.Select$100$250$500$1,000$2,500$5,000Remove DriversNameDate of Birth Add DriversNameDate of BirthDriver's License #Date of Hire AuthorizationThe undersign hereby authorizes Perry Family Insurance Agency (Agency) to make necessary changes (if they exist) to my policy (ies) to reflect the changes I have made using this form effective the date below. To my knowledge, this information is accurate as of the date below. Please have my insurance company invoice or refund our company any increase or unearned premium due to this change. The undersign holds Agency, its agents, officers, and employees harmless from all errors and/or omissions should the information on this form be incorrect. Agency staff endeavors for 100% accuracy as much as humanly possible.Name* First Last TERMS OF ACCEPTANCE and SIGNATURE*I, the authorized representative, warrant the truthfulness of the information provided in this form. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance. CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
