Pre-Renewal Insurance Questionnaire

A.  Basic Information:
1.  Company Name:
2.  Your Name:
3.  Your Title:
4.  Telephone Number to Reach You:     Ext.
5.  Your Email Address:
6.  Requests and Questions regarding Coverages
    

7.  Describe Any New or Changed Operations:
    

B.  Annual Gross Revenues:
1.  Prior 12 months: $
2.  Estimate for Coming 12 months: $

C.  Census -- Total Number & Number of Part-Time Persons:  
1.  Drivers of Company-Owned/Leased Vehicles:   
2.  Drivers Using Their Own Vehicles (owner-ops):   
3.  Bicycle Messengers:   
4.  Motorcycle/Scooter Messengers:   
5.  Foot Messengers:   
6.  Facility Management Personnel:   
     (i.e. workers supplied to other businesses)
7.  Outside Salespeople:    
8.  Executive Officers/Partners:   
9.  Office / Administrative Personnel:   

D.  Compensation Information -- Annualized 
      W2 Payroll for Employees, 1099 Figures for Independent Contractors

1.  Drivers of Company-Owned/Leased Vehicles: $   
2.  Drivers Using Their Own Vehicles (owner-ops): $   
3.  Bicycle Messengers: $   
4.  Motorcycle/Scooter Messengers: $   
5.  Foot Messengers: $   
6.  Facility Management Personnel: $   
     (i.e. persons supplied to other businesses)
7.  Outside Salespeople:  $   
8.  Executive Officers/Partners: $   
9.  Office / Administrative Personnel: $

E.  Safety and Loss Control Check-Up:
1.  Any changes in Hiring Standards or Driver Monitoring?
    

2.  Any changes in Training or Safety Programs?
    

3.  Any changes in Vehicle Maintenance or Overnight Garaging?
    

4.  Any additional changes or comments?
        

F.  Property Values: (complete appropriate boxes for each location)
Location Street Address:
1.  Computer (EDP) Equipment:  $
2.  Improvements & Betterments: $
3.  Radio Equipment Stored Overnight: $
4.  Other Business Property: $ (phones, furniture, supplies...)
5.  Building (if you own or are responsible): $.
     No other locations?  Click here to continue!

Location Street Address:
1.  Computer (EDP) Equipment:  $
2.  Betterments & Improvements: $
3.  Radio Equipment Stored Overnight: $
4.  Other Business Property: $ (phones, furniture, supplies...)
5.  Building (if you own or are responsible): $
     No other locations?  Click here to continue!

Location Street Address:
1.  Computer (EDP) Equipment:  $
2.  Betterments & Improvements: $
3.  Radio Equipment Stored Overnight: $
4.  Other Business Property: $ (phones, furniture, supplies...)
5.  Building (if you own or are responsible): $

G.  Types of Goods Transported: (as a percentage of total shipments)

1.  Documents & Light Parcels: %
     Check if maximum or average values have changed since last year & describe below
        

2.  Bulk Printed Materials: %
     Check if maximum or average values have changed since last year & describe below
        

3.  Bank Work (checks, etc.):  %
     Check if maximum or average values have changed since last year & describe below
        

4.  Computer-Related: % 
     Check if maximum or average values have changed since last year & describe below
        

5.  Medical Specimens/Supplies: %
     Check if maximum or average values have changed since last year & describe below
        

6.  Parts and Supplies: %
     Check if maximum or average values have changed since last year & describe below
        

7.  Misc. Other Commodities: %
     Check if maximum or average values have changed since last year & describe below 
        

8.  Warehousing: describe changes in types or values of items stored 
    

H.  Other Instructions Regarding Renewal? (timing, payment options, etc.)
    

Thank you for your assistance.  We will use the information you
have reported to assure you of the best value for your insurance
renewal this year.  Please do not hesitate to contact us.

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