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Business Account Review

By reviewing the checklist and submitting it to R&A Insurance, I understand that each area has been reviewed by me. I further understand that if there is an exposure or coverage change, it is my responsibility notify R&A Insurance as soon as possible. 

A record of this completed review will be kept on file at R&A Insurance. 

By submitting this form, I declare that this review was completed to my satisfaction.   

General Information
Business Name *
First Name *
Gross Receipts?
Last Name *
Mailing Address *
City and State *
ZIP / Postal Code *
E-Mail Address *
Are you authorized to make changes on the business insurance policies? *

Has the name or entity type changed?

Please list owners / officers
Has the nature of your business changed?

Have you added any new job descriptions?
Do you hire sub contractors?

Number of employees?
If you own or are responsible for insuring the building, have you reviewed the replacement value?

Have you added any of the following security

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Is your operation's income dependent on someone else's property?
Have you renovated or improved your building at your expense?

If yes, what is the current replacement cost of the building?
I am aware of the co-insurance and settlement agreement in my policy

Who owns the building you occupy?
Are you responsible for maintaining the heating / AC or other building systems?

Do you have a Cyber Liability or Data Breach Exposure?

Have you reviewed your contents,stock,raw materials, work in progress and finished goods for updated values?

Square Footage of Building
Do you own any other property?
Have you signed or changed any leases?

Lease review needed?

Do you have a disaster plan?

Link to Disaster Plan information
Would your business need Extra Expense coverage after a loss?

Would a loss of power on / off premises cause you a loss of income?

Would your business lose income if it could not operate out of your current location?

Business Interuption Worksheet?
Have you reviewed your policy for coverage that includes

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Other Important Coverage to Consider

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Do you need to review Employee Dishonesty & Fraud Coverage?

Current General Liability Limit
Per project aggregate?

Do you administer a 401k or Retirement Program?

Current Auto Liability Limit
Have you added or deleted any vehicles?

Have you changed any drivers?

Have you hired any drivers you forgot to tell us about?

Has you typical radius of driving changed?

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Would you like a copy of the drivers list we have on file?

Would you like a copy of your fleet schedule to review?

Do you have a personal auto policy?

Do you haul goods owned by others?

If so, what are you hauling?
Are you hauling any hazardous materials?

Equipment / Inland Marine / Floater
Have you reviewed your Equipment List for accuracy?

Would you like a copy of your Equipment List for your review?
Notes about above
Do you lease, borrow or rent any equipment?

Notes about above
Do you let anyone rent, borrow or lease your equipment?

Notes about above
Pollution Coverage review

Review Umbrella Policy

Workers Compensation
What States have you worked in the last 12 months?
Workers Compensation - Have your payrolls changed more than 10%?

If Yes, would you like us to send you your most current payrolls on file by class code?

Would you like a quote on Employment Practices Liability

Personal Auto, Home and Umbrella Policy review?

Business Life Insurance

Are there any other changes / coverage you wish to review?
Electronically signed by
Electronic Signature *
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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