Named Insured *

First Name

Last Name

Named of Person Completing Questionnaire *

First Name

Last Name

Renewal Date:

MM

DD

YYYY

Has you business name, ownership, or legal structure changed?

Yes

No

Has your business address or any location changed?

Yes

No

Is the mailing address the same as the business address?

Yes

No

Have there been any changes in business operations or services offered?

Yes

No

Do you anticipate any major changes in the next 12 months (e.g., expansion, new products, mergers)?

Yes

No

Have you purchased, sold, or renovated any buildings or locations?

Yes

No

Have you added or disposed of any major equipment or inventory?

Yes

No