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Insured's Name

Telephone Number

e-mail address

PLEASE ANSWER THE FOLLOWING YES OR NO QUESTIONS:

Yes

No



Do you own any other real estate besides the one listed on your policy? You should be sure that you have coverage for other property including liability. Also, your business personal property may NOT be covered at all if located at another owned property

Yes

No

Do you have any property that is not always at the address being insured on your policy. Examples may include tools, portable equipment, items at fairs or exhibitions, etc. If so, you will need additional coverage. Do you wish to add coverage for these items? Yes      No

Yes

No

If you lease a building, are you responsible for any type of loss on the building such as windows, curtains, flooring or any other tenant improvements? If so, you may need additional coverage besides just contents.

Yes

No

If your building were destroyed, would your income level drop, or would you incur extra expenses in order continue operating or to keep customers?

The policy does not have coverage for lost income or extra expenses. This coverage must be added separately. Are you interested in adding coverage for lost income or extra expenses?

Yes      No

Yes   No

Do you ever have property owned by others that is in your care, custody or control that is not always located at the insured premises address. (eg, you may send it out to a subcontractor etc)? Such property is not covered under business contents. Do you wish to add coverage so such items?

No Yes > Details ___________________

The following items are not covered in the policy. Please check those that you own or may own in the future. For each one that you answer "yes", please check whether you wish to discuss further.

                     Discuss

Own?        Further?

Yes   No      Yes     No

        Accounts, bills, currency, deeds, food stamps

       Animals

        Automobiles, vehicles or self propelled machines

        Bridges, roadways, walks, patios, or other paved surfaces

        Cost of excavations, backfilling or filling

        Underground pipes, flues or drains

        Grain, hay, straw, or other crops

Yes   No

Are your limits too low? ie Do you think the limit of coverage is less than the value of your property or less than the cost to replace it? If so, please discuss this with your agent.

Yes    No

For Debris Removal, the policy will pay no more than 25% (as an additional coverage) of the amount paid for physical loss to the covered property. Do you think you need extra coverage for this? If so, discuss with an agent.

Yes   No

Does your fire department charge you if they must come out for a fire? Typically, there is a limit of $500 to $1,000 for fire dept charges. Are you concerned with this? No Yes

YesNo

Is there any chance of pollutants getting into your land, buildings, or water or any chance of you causing or appearing to have caused discharge, seepage, release, etc. of pollutants? There are exclusions relating to paying for the extraction of pollutants. In addition, there is no liability coverage should you be sued for pollution related items. Are you concerned? No Yes

Yes   No

Do you have any valuable papers or records including those on electronic or magnetic media? There is no coverage or limited coverage for the cost to research, replace or restore information on these items. You may be able to add or increase the limit. Are you concerned about this? No Yes

Yes   No

Do you have any outdoor fences, radio or television antennas, signs, or trees, shrubs, or plants? There is no coverage or limited coverage. You may be able to add or increase the limit. Are you concerned about this? No Yes

Yes   No

Is the covered or leased building ever vacant for more than 30 consecutive days? There are several limitations in this case including no coverage for several perils (including vandalism, theft, glass breakage, water damage, sprinkler system leakage, etc.). In addition, for the perils that are still covered, the amount that would be paid for a loss is reduced.

Are you concerned about this? No Yes

Yes   No

Do you have any windows or doors containing glass? Glass breakage is very limited on the policy. If you are concerned, you should add separate glass coverage. Do you wish to add coverage for glass? No Yes

Yes   No

Would anything need to be re-built differently in order to meet current building code? There is no coverage for this or any required tearing down of any property. You may be able to add it.

Are you concerned about this? No Yes

Yes   No

Co-insurance clauses are typical and create penalties if you are not insured to a "proper" limit at the time of loss. Are you concerned about this or do you wish to have a more detailed explanation?

Yes   No

Are you concerned with coverage for earth movement including earthquake? This is exlcluded from most policies. You may be able to add it. Do you wish to add coverage? No Yes

Yes   No

The following "perils" are excluded: volcanic eruption or explosion; nuclear related items; governmental actions including seizure or destruction, war or military action; artificially generated electric current; insects, birds or other animals, computer viruses. Are you concerned with any of these?

Yes   No

Do you have anything that could be damaged should the electricity go out?

There is no coverage for power failure or lack of electricity. You may be able to add some coverage.

Do you wish to add coverage or discuss further? No Yes

Yes   No

Do you have anything that could be damaged by water including flood, mudslide, water backup through drains or water under the ground survface? These are all excluded on the policy. You may be able to purchase flood insurance or add some limited coverage for backup of water through drains. Do you wish to add coverage or discuss further? No Yes

Yes   No

Do you have important mechanical items that could cause a loss should they break down including computers, air conditioner, furnace, etc.? Mechanical breakdown is not covered. You may be able to add it. Do you wish to add coverage? No Yes

Yes   No

Do you own, or does the building contain any boilers, steam pipes, steam engines?

There is no coverage for exposion of any of these items. You may be able to purchase separate coverge if you wish.

Do you wish to add coverage? No Yes

Yes   No

Do you keep any property in the open?

Coverage is very limited including no coverage for rain, snow, ice or sleet.

LIABILITY

Yes   No

Is your liablity limit too low? ie If you were to be sued, would your limit of liability be enough to cover all the legal expenses as well as the judgement or settlement? Discuss this with your agent.

Yes   No

Do you have or do you ever sign contracts where you assume any liability? You may not have coverage. Refer to the policy for what types of contracts are "acceptable".

Yes   No

Do you sell, manufacture or distribute any type of alcoholic beverages?

If so, there is no coverage for liquor liability. Even if you don’t, coverage is limited. You need a separate liquor liability policy.

Yes   No

Do you have any employees?

Of course, your general liablity does not cover any type of injury to employees. You should have a workers comp policy.

Yes   No

Does your company ever lease, hire, rent, or borrow any automobiles or other vehicles?

There is no coverage automatically for the company’s liability for these vehicles (either on this or on a commercial auto policy). You need to add coverage called "Hired Auto Liability" to either your general liability policy or your auto policy. Do you wish to add this coverage? No Yes

Yes   No

Do employees ever use their own autos for company business or errands? There is no coverage for liability should the company be sued because the employee injured someones person or property (either on this or a commercial auto policy). You will need to add coverage called "Employers Non-Ownership Liability" to either our general liability or your auto policy.

Do you wish to add this coverage? No Yes

Yes   No

Is there a chance of damaging or incorrectly installing your product?

There is no coverage for property damage liability for anything relating to your own work or property in your care, custody or control. For example, if you are installing a window and drop it, there is no coverage (however, if, when you drop it, it lands on your customer’s antique desk and scratches it all up, then that would be a covered item under property damage liability). Or if you paint a room pink that was supposed to be blue, there is no coverage. You may be able to add back som limited coverage for property in your care, custody and control Do you wish to do so? No Yes

OTHER MISCELLANEOUS QUESTIONS:

Yes   No

Do you have any assets susceptible to a law suit? We recommend that all companie have what is called an "Umbrella" policy. This is a liability policy that "blankets" over your general liability, commercial auto, and workers compensation insurance in case you are sued. Limits start at $1 million and it would "kick" in when you have used up your underlying limits from the other policy. With law suits going the way they are, this is a good thing to have and it is quite inexpensive. Do you wish to discuss this further? No Yes

Yes   No

Were you made aware at the time we provided a quote that Abbott & Fillmore can obtain quotes for you and place coverage from several different, competing insurance companies?

Yes   No

Were you told that, if you question your rate sometime in the future, you can call Abbott & Fillmore and request a "RE-QUOTE" to be sure you are still receiving the lowest rate from several companies? This is our exclusive "Re-Quote Service".

Yes   No

Did you know that Abbott & Fillmore may be able to obtain significant discounts for you by packaging several policies together including personal policies and life insurance on the company’s owners/officers? Would you like us to give you a quote on other insurance sometime? No Yes> What type of insurance and when do you prefer? ___________

Yes   No

Is your workers compensation insurance currently with Abbott & Fillmore?

Yes   No

Is your commercial auto insurance currently with Abbott & Fillmore?

Yes   No

Is your group health insurance currently with Abbott & Fillmore?

Yes   No

Is your officers’ personal life insurance currently with Abbott & Fillmore?

Yes   No

Is your officers’ personal auto & home ins. currently with Abbott & Fillmore?

Yes   No

Is your officers’ long term care insurance currently with Abbott & Fillmore?

I understand that the above questions are used by Abbott & Fillmore Agency to help me highlight areas which may not be covered under a standard commercial insurance policy and to determine areas where I may be at risk. I also understand that it is no way a substitute for reading my policy. There are many conditions, exclusions, etc. in an insurance policy and I will review my policy for the details. In addition, if any of the above items change, I am aware that I should contact my agent to make sure I am covered to my satisfaction.. Finally, if I would ever like Abbott & Fillmore to compare my rates with other insurance companies, I will contact them.

Name of Person Completing Form:

Yes No	Do you own any other real estate besides the one listed on your policy? You should be sure that you have coverage for other property including liability. Also, your business personal property may NOT be covered at all if located at another owned property
Yes No	Do you have any property that is not always at the address being insured on your policy. Examples may include tools, portable equipment, items at fairs or exhibitions, etc. If so, you will need additional coverage. Do you wish to add coverage for these items? Yes No
Yes No	If you lease a building, are you responsible for any type of loss on the building such as windows, curtains, flooring or any other tenant improvements? If so, you may need additional coverage besides just contents.
Yes No	If your building were destroyed, would your income level drop, or would you incur extra expenses in order continue operating or to keep customers? The policy does not have coverage for lost income or extra expenses. This coverage must be added separately. Are you interested in adding coverage for lost income or extra expenses? Yes No
Yes No	Do you ever have property owned by others that is in your care, custody or control that is not always located at the insured premises address. (eg, you may send it out to a subcontractor etc)? Such property is not covered under business contents. Do you wish to add coverage so such items? No Yes > Details ___________________
	The following items are not covered in the policy. Please check those that you own or may own in the future. For each one that you answer "yes", please check whether you wish to discuss further. Discuss Own? Further? Yes No Yes No Accounts, bills, currency, deeds, food stamps Animals Automobiles, vehicles or self propelled machines Bridges, roadways, walks, patios, or other paved surfaces Cost of excavations, backfilling or filling Underground pipes, flues or drains Grain, hay, straw, or other crops
Yes No	Are your limits too low? ie Do you think the limit of coverage is less than the value of your property or less than the cost to replace it? If so, please discuss this with your agent.
Yes No	For Debris Removal, the policy will pay no more than 25% (as an additional coverage) of the amount paid for physical loss to the covered property. Do you think you need extra coverage for this? If so, discuss with an agent.
Yes No	Does your fire department charge you if they must come out for a fire? Typically, there is a limit of $500 to $1,000 for fire dept charges. Are you concerned with this? No Yes
YesNo	Is there any chance of pollutants getting into your land, buildings, or water or any chance of you causing or appearing to have caused discharge, seepage, release, etc. of pollutants? There are exclusions relating to paying for the extraction of pollutants. In addition, there is no liability coverage should you be sued for pollution related items. Are you concerned? No Yes
Yes No	Do you have any valuable papers or records including those on electronic or magnetic media? There is no coverage or limited coverage for the cost to research, replace or restore information on these items. You may be able to add or increase the limit. Are you concerned about this? No Yes
Yes No	Do you have any outdoor fences, radio or television antennas, signs, or trees, shrubs, or plants? There is no coverage or limited coverage. You may be able to add or increase the limit. Are you concerned about this? No Yes
Yes No	Is the covered or leased building ever vacant for more than 30 consecutive days? There are several limitations in this case including no coverage for several perils (including vandalism, theft, glass breakage, water damage, sprinkler system leakage, etc.). In addition, for the perils that are still covered, the amount that would be paid for a loss is reduced. Are you concerned about this? No Yes
Yes No	Do you have any windows or doors containing glass? Glass breakage is very limited on the policy. If you are concerned, you should add separate glass coverage. Do you wish to add coverage for glass? No Yes
Yes No	Would anything need to be re-built differently in order to meet current building code? There is no coverage for this or any required tearing down of any property. You may be able to add it. Are you concerned about this? No Yes
Yes No	Co-insurance clauses are typical and create penalties if you are not insured to a "proper" limit at the time of loss. Are you concerned about this or do you wish to have a more detailed explanation?
Yes No	Are you concerned with coverage for earth movement including earthquake? This is exlcluded from most policies. You may be able to add it. Do you wish to add coverage? No Yes
Yes No	The following "perils" are excluded: volcanic eruption or explosion; nuclear related items; governmental actions including seizure or destruction, war or military action; artificially generated electric current; insects, birds or other animals, computer viruses. Are you concerned with any of these?
Yes No	Do you have anything that could be damaged should the electricity go out? There is no coverage for power failure or lack of electricity. You may be able to add some coverage. Do you wish to add coverage or discuss further? No Yes
Yes No	Do you have anything that could be damaged by water including flood, mudslide, water backup through drains or water under the ground survface? These are all excluded on the policy. You may be able to purchase flood insurance or add some limited coverage for backup of water through drains. Do you wish to add coverage or discuss further? No Yes
Yes No	Do you have important mechanical items that could cause a loss should they break down including computers, air conditioner, furnace, etc.? Mechanical breakdown is not covered. You may be able to add it. Do you wish to add coverage? No Yes
Yes No	Do you own, or does the building contain any boilers, steam pipes, steam engines? There is no coverage for exposion of any of these items. You may be able to purchase separate coverge if you wish. Do you wish to add coverage? No Yes
Yes No	Do you keep any property in the open? Coverage is very limited including no coverage for rain, snow, ice or sleet.
	LIABILITY
Yes No	Is your liablity limit too low? ie If you were to be sued, would your limit of liability be enough to cover all the legal expenses as well as the judgement or settlement? Discuss this with your agent.
Yes No	Do you have or do you ever sign contracts where you assume any liability? You may not have coverage. Refer to the policy for what types of contracts are "acceptable".
Yes No	Do you sell, manufacture or distribute any type of alcoholic beverages? If so, there is no coverage for liquor liability. Even if you don’t, coverage is limited. You need a separate liquor liability policy.
Yes No	Do you have any employees? Of course, your general liablity does not cover any type of injury to employees. You should have a workers comp policy.
Yes No	Does your company ever lease, hire, rent, or borrow any automobiles or other vehicles? There is no coverage automatically for the company’s liability for these vehicles (either on this or on a commercial auto policy). You need to add coverage called "Hired Auto Liability" to either your general liability policy or your auto policy. Do you wish to add this coverage? No Yes
Yes No	Do employees ever use their own autos for company business or errands? There is no coverage for liability should the company be sued because the employee injured someones person or property (either on this or a commercial auto policy). You will need to add coverage called "Employers Non-Ownership Liability" to either our general liability or your auto policy. Do you wish to add this coverage? No Yes
Yes No	Is there a chance of damaging or incorrectly installing your product? There is no coverage for property damage liability for anything relating to your own work or property in your care, custody or control. For example, if you are installing a window and drop it, there is no coverage (however, if, when you drop it, it lands on your customer’s antique desk and scratches it all up, then that would be a covered item under property damage liability). Or if you paint a room pink that was supposed to be blue, there is no coverage. You may be able to add back som limited coverage for property in your care, custody and control Do you wish to do so? No Yes

Yes No	Do you have any assets susceptible to a law suit? We recommend that all companie have what is called an "Umbrella" policy. This is a liability policy that "blankets" over your general liability, commercial auto, and workers compensation insurance in case you are sued. Limits start at $1 million and it would "kick" in when you have used up your underlying limits from the other policy. With law suits going the way they are, this is a good thing to have and it is quite inexpensive. Do you wish to discuss this further? No Yes
Yes No	Were you made aware at the time we provided a quote that Abbott & Fillmore can obtain quotes for you and place coverage from several different, competing insurance companies?
Yes No	Were you told that, if you question your rate sometime in the future, you can call Abbott & Fillmore and request a "RE-QUOTE" to be sure you are still receiving the lowest rate from several companies? This is our exclusive "Re-Quote Service".
Yes No	Did you know that Abbott & Fillmore may be able to obtain significant discounts for you by packaging several policies together including personal policies and life insurance on the company’s owners/officers? Would you like us to give you a quote on other insurance sometime? No Yes> What type of insurance and when do you prefer? ___________
Yes No	Is your workers compensation insurance currently with Abbott & Fillmore?
Yes No	Is your commercial auto insurance currently with Abbott & Fillmore?
Yes No	Is your group health insurance currently with Abbott & Fillmore?
Yes No	Is your officers’ personal life insurance currently with Abbott & Fillmore?
Yes No	Is your officers’ personal auto & home ins. currently with Abbott & Fillmore?
Yes No	Is your officers’ long term care insurance currently with Abbott & Fillmore?