Legal Business Name

Your Name

First Last

Phone

Business Review Sections

A business risk evaluation involves completing the sections of this form that are applicable to your business. You can deselect the options below that do not apply to your business.

General Operations

Real Property

Commercial Vehicle(s)

Business Staffing

Coverage Assessment

General Operations Review

This section will help identify changes to your business in order to evaluate new risks.

Has the legal name of your business changed?

Yes

New Legal Business Name

Has the mailing address of your business changed?

Yes

New Mailing Address

Street Address Address Line 2 City State ZIP Code

Has the ownership structure of your business changed?

Yes

Please tell us about the new ownership structure

Is any of the following new with your business?

Select all that apply.

New Service(s)

New Product(s)

New Machinery / Equipment

New State(s) / Countries Expanded To

New Entity Formed (Corporation, Partnership, LLC)

Other

None

Please tell us what is new with your business

What is the Other new thing with your business?

What is your annual gross revenue this year?

Real Property Review

Let's begin reviewing your real property such as assets, buildings, equipment, machinery, etc.

Do you have a recent property appraisal showing replacement cost of any building the business owns or is responsible for?

Yes

What is the replacement cost?

Upload copy of appraisal

Drop files here or

Max. file size: 2 MB, Max. files: 1.

More than one location?

Yes

Additional Location(s)

Location Address	Square Feet	Actions

There are no Locations.

Maximum number of locations reached.

Have you added or removed any security alarms, bars, or other protective devices?

Yes

Please briefly explain details about security added or removed.

Has the occupancy status of any building changed?

Examples: rented, vacant, under renovations, etc

Yes

Not sure

Please explain any occupancy status change for any location(Required)

Do you use a property management company?

Yes

Does the business have any properties that we do not currently insure?

Yes

Did the business earn rental income last year?

Yes

What will the annual rental income be this year?(Required)

What is the estimated annual rental income next year?(Required)

Does the business own any outdoor property?

Check all that apply

Sign(s)

Lighting

Generator

Fencing

Other

Explain other outdoor property

Commercial Auto Review

This area will help identify some common changes and updates to commercial auto exposures.

Has the business purchased or leased any new vehicles

Yes

New Vehicle List

VIN	Year	Make	Model	Actions

There are no Vehicles.

Maximum number of vehicles reached.

Any new drivers to be added?

Yes

New Drivers List

Driver Name	Drivers License Number	Drivers License State	Actions

There are no Drivers.

Maximum number of drivers reached.

Do you allow employees to use your personal vehicle for business use?

Yes

Business Staffing Review

This section will help identify risk exposures related to your staff.

How many employees do you currently have?

Has your employee payroll changed significantly of the last 12 months?

Yes

Please describe your employee payroll change(Required)

Examples: New employees, etc.

Projected payroll for the next 12 months?(Required)

Do you want to INCLUDE any Partners, Officers, Owners, or Relatives in workers comp coverage?(Required)

None

Partner(s)

Officer(s)

LLC Member(s)

Owner(s)

Relative(s)

Do you want to EXCLUDE any Partners, Officers, Owners, or Relatives from workers comp coverage?(Required)

None

Partner(s)

Officer(s)

LLC Member(s)

Owner(s)

Relative(s)

Does your business use subcontractors?

Yes

Approximate percentage of work performed by subcontractors?(Required)

Example: 25%

Do you require subcontractors to provide Proof of Insurance and name your business as Additional Insured?

Yes

Unsure

Do you provide health insurance for employees?

Yes

Do you provide disability insurance for employees?

Yes

Coverage Assessment

This section will help uncover any additional exposures to risk. Please note that coverage for certain areas may already be in place, but it is helpful to continue to assess these risks on an ongoing basis.

Does your business have machines or electrical equipment that may be susceptible to breaking down?

Examples: A/C, elevators, pumps, etc.

Yes

Do employees have access to cash or stock?

Yes

Please select the type(s) of information your business collects.

Check all that apply

Credit Cards

Personally Identifying Information

Tenant Personal Information

Vendor Information

None of these

Please select the different ways your business used the internet.

Check all that apply

Online Sales

Internet Advertising

Social Media

None of these

Other

What other ways does your business use the internet?(Required)

Has your business total expenses changed in the last 12 months?

Yes

Do you expect your business to grow over the next 2 years?

Yes

Unsure

Has your business's dependency on any one customer or supplier, including overseas, changed in the past 12 months, or likely to change moving forward?

Yes

Unsure

Does your business ship or receive goods?

Yes

Unsure

Does your business provide advice for a fee?

Yes

Does the business have key employees that would require time and money to replace if they were to unexpectedly pass away?

Yes

Unsure

Is income replacement coverage needed to protect key employees if they are unable to work due to chronic illness or disabling accident?

Yes

Unsure

Have you reviewed your business liability insurance program to ensure the adequacy of the limits?

Yes

Wrapping Up

Additional Comments

Documents

Upload any relevant documents for review. Examples: Property appraisals, certificate requests, etc.

Drop files here or

Max. file size: 12 MB.

Your Agent

Consumer Disclosure(Required)

By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.

I Agree

DISCLAIMER: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

This field is for validation purposes and should be left unchanged.

ROI Insurance Solutions

5205 Kearny Villa Way, Suite 101

San Diego, California 92123

Phone: 858-569-2030
Fax: 858-277-4901

Monday	8:00 AM - 5:30 PM
Tuesday	8:00 AM - 5:30 PM
Wednesday	8:00 AM - 5:30 PM
Thursday	8:00 AM - 5:30 PM
Friday	8:00 AM - 5:30 PM