Policy Review - Dougherty Insurance Agency

Client Information

Name

First Name Last Name

Email

Phone Number

What insurance do you currently have with us?

Personal Insurance

Business Insurance

Home Address

Street Address Address Line 2 City State ZIP Code

Company Name

Company Address

Street Address Address Line 2 City State ZIP Code

Total Annual Sales

Total Number of Employees

Your Business Structure

Please think back over the last year when answering these questions.

Have you changed the ownership structure of your business?

Yes

No

Have you added new or changed your existing operations and/or products?

Yes

No

Have you begun to buy supplies or sell your products overseas?

Yes

No

Are you operating out of any new locations or have you closed locations?

Yes

No

Please explain any changes to your business structure.

Please do not include sensitive, private information in this area.

Your Personal Liability

Please think back over the last year when answering these questions.

Have you acquired, leased or sold a building, business property and/or equipment?

Yes

No

Have there been any improvements and/or significant alterations to your building?

Yes

No

Has your inventory level changed significantly?

Yes

No

Have you purchased, leased or sold any Vehicles?

Yes

No

Please explain any changes to your personal liability.

Please do not include sensitive, private information in this area.

Your Income Protection

Please think back over the last year when answering these questions.

Have your Businesses revenues changed by more than 10% since last year?

Yes

No

Do you rely on a single supplier for more than 50% of your materials?

Yes

No

Do you rely on a single buyer for more than 50% of your sales?

Yes

No

Please explain any changes to your income protection.

Please do not include sensitive, private information in this area.

Additional Protection

Need additional insurance? Just let us know how we can help.

Would you like to discuss any additional insurance protection with our firm?

Yes

No

Confirmation

Your initials

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

Make sure your insurance fits your needs with a policy review.

Things change over time, and your insurance should reflect that. Compare your coverage with a policy review.

Client Information

Your Home(s)

Your Automobiles and other "Vehicles"

Your Other Life Events

Your Business Structure

Your Personal Liability

Your Income Protection

Your Employees & Professional Liability Exposure

Additional Protection

Confirmation