ࡱ> }|q` @bjbjqPqP .v::8####L4$MZ$$$$$CCCYYYYYYY$[he^YF7 CFFY$$;ZHHHF $$YHFYHHUdY$$ PE^CP#FrhXYZ0MZzX_H_$dY_dYhCvCTHIDDDCCCYYH CCCMZFFFFD## Huggins/Dreckman Insurance Agency, Inc. P O Box 20395, Long Beach, CA 90801, Phone: 800-400-3224 Fax: 562-594-0376; License 0212199 Please Complete This Worksheet and Return! REVIEW OF COMMERCIAL INSURANCE POLICIES Name of Your Business: __________________________________________ Contact Person: _____________________________ / Phone: _____________ Avoid the 6 Most Dreaded Words in Insurance Im Sorry But Thats Not Covered Enclosed is a Commercial Protection Review Checklist and we ask that you review these items, mark any changes, sign, and return to our office in the next (15) fifteen days. Also, enclosed for your convenience is a Summary of Insurance that you may want to reference when completing the checklist. There are no wrong answers and your response will enable us to discuss coverage Concerns and provide recommendations. We understand that you may already have coverage for some of these areas. Your answers will help us to understand your desires in the event of a loss. Please return to us in the enclosed envelope or fax back to us at 562-594-0376 Thank you for allowing us to handle your insurance needs. We appreciate your business very much! Sincerely, Stan Dreckman P.S. This simple review really can eliminate 37% of all claims problems! GENERAL Yes No Have you formed any new business entities such as a corporation, partnership, joint venture, LLC, or profit sharing plan? ________________________________________________________________________ Other than policies that appear on the attached Summary of Insurance, do you carry any other policies on your business through another insurance agency? Please list: Policy Type_______________ Agency/Insurance Co.______________________ Policy Type_______________ Agency/Insurance Co.______________________ Do you enter into any types of contracts (ex: premises lease, personal property lease, employee lease, construction contracts, shipping contracts, etc.) that require you to carry certain insurance policies? If so, please list the types of contracts and forward a copy for our review (unless you have already done so) to make sure that you are in compliance. _____________________________________________ WORKERS COMPENSATION 1. WARNING! If you dont currently carry a Workers Compensation policy, you are required to file Texas Workers Compensation Commission form TWCC-5. This form needs to be filed annually with the TWCC that you are electing to be a Non-Subscriber to The WC Act. We can send this form and instructions, let us know if you need this form. Do you want us to provide a quote? (Dont answer this question if you already carry a policy). **Only answer questions 2 through 10 below if you carry a Workers Compensation policy** How many employees, including owners, will you have over the next 12 months? Will your overall payrolls be up, down, or the same? __________________________________________________________________ Yes No  Do you plan on using any subcontractors over the next 12 months? If yes, what type of work will they perform? If yes, will they provide you with a certificate of insurance evidencing that they carry their own Workers Compensation? (No___ Yes___)  As of the renewal date of your policy, do you have any work scheduled to be performed or employees to be located outside of your home state? If yes, please indicate the states: _________________________________________________  Will any employees be traveling outside the US or Canada? If yes, to what countries? If yes, will it be for more than 30 consecutive days (No___ Yes___) Do you do any work that falls under the jurisdiction of federal compensation laws such as US Longshoremen and Harbor Act, Jones Act, Federal Employers Liability Act, Foreign Defense Base Act, etc.? ___________________________  7. Do you lease any employees from an Employee Leasing Company or PEO?  8. If your owner(s) is/are excluded from Workers Compensation coverage, do you want a quote for Health Insurance, Disability Income, or Life Insurance to make up for the benefits that are lost by being excluded? ________________________  9. Can you document that you have a drug free workplace plan in effect? 10. Are you interested in implementing a formal safety program? GENERAL LIABILITY **Only answer the questions below if you carry a General Liability policy** If you were sued for $797,000 more than your Each Occurrence Limit of Coverage (see enclosed Summary of Insurance) would you want your insurance company to pay for this? What are your estimated gross sales revenues for the next 12 months? $________ Estimated annual payrolls for your non office/clerical employees $________ Do you use any subcontractors? If yes, do they provide you with a Certificate of Insurance indicating that they carry their own General Liability insurance with an Each Occurrence Limit equal to yours (No___ Yes___)? If a disgruntled employee were to sue you for $250,000 plus punitive damages for alleged discrimination, sexual harassment, or wrongful termination, would you want your policy to cover this for an additional premium charge which would likely be at least $2,500?  Do you ever serve alcoholic beverages where you make a charge or where a permit is required to be taken out?  If an alleged negligent act, error, or omission that arose out of your professional services were to result in economic damages (not related to physical injury) of $135,000 to your client, would you want your insurance to cover this for an additional premium charge of which would likely be at least $1500? If you provide employee benefits to your employees such as Group Health insurance, would you want coverage if you were sued for making an administrative error such as failing to add a new employee to the plan, and if such employee incurred $120,000 in uncovered medical bills as a result? The additional premium would be approximately $250. If you were sued for managerial negligence that resulted in economic damages to a minority owner of your company or for violations of federal, state, or constitutional rights to other third parties, would you want this to be covered? The likely premium charge would be at least $5,000. Would you like to purchase any of the following coverages that are excluded under your policy for an additional premium charge? Please circle: E Commerce Liability due to your website, Product Recall, Advertisers Liability, Pollution Liability, Patent Infringement. Do your employees ever use their own vehicles to conduct business or run errands on your behalf? Do you ever lease vehicles for short term use such as when you fly out of town? BUSINESS AUTO **Only answer questions 2 through 10 below if you carry a Business Automobile policy** Please see the enclosed Summary of Insurance that will provide a list of vehicles covered, lien holders, drivers, and limits of liability for Auto Liability, Uninsured Motorists, Underinsured Motorists, and Comprehensive/Collision (if any). Does any of this information need to be updated? ______________________________ If you are involved in an auto accident where you are sued for $450,000 more than your Auto liability limit (see enclosed Summary of Insurance), do you want the insurance company to pay for all of the claim? Do you ever lease vehicles for short-term use such as for a special delivery or when you fly out of town and get a rental car to conduct business? If the answer to 3 above is yes, do you always buy the Collision Damage Waiver from the rental car company? Do you or any of your employees, (including yourself), who use vehicles on the enclosed Summary of Insurance not have a Personal Auto Policy covering a vehicle that is owned within their household?  Do you haul materials that would require a MCS-90, PSC, or ICC filing?  Do you ever drive or garage your customers cars or provide valet parking? Do you have any vehicles that are titled in your individual name instead of your business name? If yes, list: Year____________ Make____________ Model________________ Owners Name_________________________ Yes No Do any vehicles have customized equipment (ex: shell on pickup, rack, etc.) that was not installed by the original manufacturer? If yes, do you want it covered?  Do any vehicles have customized electronic devices such as CB radios, mounted cell phones, CD Player, or GPS navigation systems that were not installed by the original manufacturer? If yes, do you want it covered?  Would you definitely be interested in increasing your deductible on your Comprehensive/Collision (if any) to save money?  Do you always check the Motor Vehicle Record (MVR) of a driver before allowing them to drive your vehicle? PROPERTY **Only answer questions 2 through 10 below if you carry a Business Property policy** Please see the enclosed Summary of Insurance that will provide a list of covered locations, building limits, personal property limits, business income limits, mortgagees, lien holders, etc. (if any). Are the insured values listed for each coverage sufficient to cover the full Replacement Cost should such property be totally destroyed by Fire, Tornado, etc.? (WARNING! If the limits are not high enough you may be subject to a Coinsurance Penalty which may reduce the claim amount that you collect in the event of a partial loss.) Have you recently upgraded or made additions to your covered buildings or personal property with a cost over $5,000 that has not been reported to us? If so, please indicate what was done and the cost: _________________________________________________________________ Have you recently updated any of the following: heating/AC, plumbing, wiring, roof? (Please circle and provide year):__________________________________ Have you recently installed a central station fire and burglar alarm that has not been reported to us? Would you definitely consider increasing your deductible (see enclosed Summary of Insurance) to lower your premium? Danger! Every Property Insurance policy has internal sub-limits. Please indicate the amount of coverage you need (if any) for each of the following special types of property, (If no coverage is needed, please indicate 0): Computer Hardware $______________ Computer Software $______________ Personal Property Titled To Others: (ex: Held on Consignment, Stored for Shipping, etc.) $______________ Incoming Shipments from Suppliers $______________ (amount needed for 1 truckload, etc.) Outgoing Shipments To Customers $______________ (amount needed for 1 truckload, etc.) Your Personal Property While Away From the Premises $______________ Cost to Reproduce Valuable Papers (ex: blueprints, customer files) $______________ Money/Notes/Securities at your Premises $______________ Fine Arts/Collectibles at your Premises $______________ Personal Articles Owned by your Employees $______________ Patterns/Molds/Dies $______________ Contractors Equipment Taken Off Premises $______________ Value of Jobs being Installed (labor, materials, overhead, profit, etc.) $______________ Glass Coverage $______________ Sign Coverage $______________ Display Booths at Trade Shows $______________ Outdoor Property (fences, lights, satellite dish, antennae, etc.) $______________ WARNING! These perils are not covered unless added back to your policy by endorsement (see enclosed Summary of Insurance): Flood, Earthquake, Electrical Injury Caused by Artificially Generated Power Surges or Loss of Power, (ex: blackout, brownout, car hits telephone pole with transformer), Boiler Explosion, Loss of Power/Water/Communications, etc. Please circle the perils that you would like to receive a quote on. If a loss to your property caused your business to shut down for an extended period would you need money to continue salaries or other expenses?  Are you dependent on one or several unique suppliers or customers to the extent that a shut down of their business for an extended period would hurt your business? Are you dependent on your website for a significant portion of your revenues? If yes, do you want coverage in the event that your website is shut down by hackers or malicious virus/worm?  If an employee stole money from your business, would you want it paid back? FINANCIAL If a key person in your business were to die, would you like for the insurance company to pay your business for loss of the employees unique services? If you get sick or injured and cant work for 7-13 weeks or longer, would you like for your insurance company to make the payments of your ongoing business expenses? With whom do you have your life insurance now? Could we review your policies for you? Would you like a Free quote for additional insurance? __________________________________________________________________ OTHER 1.. What is your e-mail address? __________________________________________ 2. Would you like to schedule an appointment for a phone review or in-office visit to discuss your insurance program? 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