Policy Renewal - The Salvati Insurance Group

Commercial Insurance Policy Renewal

We are more than a commercial insurance provider. Our firm offers a wide range of insurance services to meet all your needs. Please let us know if you would also be interested in receiving a quote or information about any of the following services:

Personal Home and Auto Insurance
Individual Life and Health Insurance
Group Employee Benefits
Medicare for Individuals or employee retirement plans

Remember, bundling your insurance needs can often provide more comprehensive coverage and potential cost savings. Let us help protect all aspects of your life and business.

Thank you for taking the time to fill out this form. We value your business and look forward to continuing to serve your insurance needs.

"*" indicates required fields

1Business and Contact Information

2General Questions

3General Liability

4Coverage Needs

Business Name*

Name of Person Filling Out the Form*

Email*

Preferred Phone Number*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Is the Named Insured shown on your policy(ies) correct?*

Yes

N/A

Please provide correct details*

Have there been any changes in operations, exposures, products, services, new joint ventures/partnerships, or equipment in the past year?*

Yes

N/A

Please describe the changes*

Do you conduct business online (e.g., selling, buying, taking payments)?*

Yes

N/A

Would you like a quote for eCommerce coverage?*

Do you export any products, have employees, or any locations outside the U.S.?*

Yes

N/A

Please explain*

What is your Estimated Gross Annual Revenue for the upcoming term?*

How many employees do you have?*

What are your estimated subcontracting costs for the upcoming term, if any?*

Have there been any changes in your business operations?*

Yes

Are you interested in higher liability limits on your primary (General Liability, Auto, etc.) or Excess Liability policies (Umbrellas) ?*

Yes

N/A

Do you employ any workers (full-time or part-time)?*

Yes

N/A

How many full time workers?*

How many part-time workers?*

Please tell us the payroll / employee (estimated yearly)*

What are their job roles?*

Do you use any sub-contractors?*

Yes

N/A

Do you want to discuss protection for employee allegations of discrimination, harassment, etc. considering the high cost of defending against potential litigation?*

Yes

N/A

Do you sell, distribute, or serve alcohol?

Yes

N/A

Are your business autos titled in a name other than the business name on your auto policy?*

Yes

N/A

Please provide details*

Do you or your employees use personal vehicles in the business (including running errands, picking up mail, etc.)?*

Yes

N/A

Do you have a personal auto use policy?*

Yes

Are you interested in a quote for any of the following coverage options? (Select all that apply)

Group & Individual Medicare Insurance

Group & Voluntary Employee Benefits

Group & Individual Life Insurance (Keyman)

Personal Health Insurance

Personal Home & Auto Insurance

Annuities & Financial Services

Cyber Insurance

Other

Which coverages are you interested in?

Are there any other questions or concerns we can address for you?*

Yes

Please provide details*

Personal Policy Renewal

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Name of Policy Holder*

Phone number*

Email address*

Are there children in the household?*

Yes

Age of child in the household*

Add new line for each of the children

Are there any new household members or newly licensed drivers in the household?*

Yes

Additional information*

Name of driver

Date of birth

License number

Occupation

Does your home have a monitored security system or local alarm?*

Yes

Who is your provider?*

Do you have a Boat to Insure?*

Yes

Boats to insure*

Year

Make

Model

CCs / horsepower

Appraised value

Do you have a snowmobile to insure?*

Yes

Snowmobiles to insure*

Year

Make

Model

CCs / horsepower

Appraised value

Do you have a motorcycle/RV to insure?*

Yes

Motorcycle/RV to insure*

Year

Make

Model

CCs / horsepower

Appraised value

Do you own a seasonal home?*

Yes

More Info*

Do you have a pool?*

Yes

Pool Size*

Max Depth*

pool is above ground?*

Yes

Is your pool fenced?*

Yes

Does the pool have a slide?*

Yes

Is there a diving board?*

Yes

Do you have a trampoline?*

Yes

Do you have a net around the trampoline?*

Yes

Any updates to the roof?*

Yes

What year was the update?*

What work was done?*

Any updates to the electrical?*

Yes

What year was the update?*

What work was done?*

Any updates to the plumbing?*

Yes

What year was the update?*

What work was done?*

Any updates to the hot water heater?*

Yes

What year was the update?*

What work was done?*

Any updates to the bathrooms?*

Yes

What year was the update?*

What work was done?*

Any updates to the kitchen?*

Yes

What year was the update?*

What work was done?*

Any updates to the basement?*

Yes

What year was the update?*

What work was done?*

Any additions to the home or any newly built structures on the premises?*

Yes

Provide details*

Do you have a mortgage?*

Yes

Who pays the home insurance?*

paid by owner

escrowed with your mortgage payment

Are there any dogs on premises?*

Yes

How many dogs?*

What breed(s)?*

Have you purchased any high ticket items in the last year?*

Yes

Jewelry, electronics, collectables etc

Provide details and value*

Are any vehicles used for Uber, Lyft, Shipt or delivery?

Yes

More info*

Any vehicles not titled to you or your spouse?*

Yes

Details*

Do any vehicles have any business logos or signs on them?*

Yes

More details*

Has your medical insurance changed in the last year?*

Yes

Name of the provider*

Is this a waterfront location?*

Yes

Do you have a seawall?*

Yes

Do you want sea wall coverage?*

Yes

How much?*

details*

Would you like an Umbrella Quote?*

Yes

Would you like a Flood Insurance Quote?*

Yes

Would you like more information on:

Medicare Insurance

Commercial Insurance

Group & Voluntary Benefits

Individual Life Insurance

Personal Health Insurance

Annuities & Financial Services

Other

Which other insurances would interest you?*

Group Policy Renewal

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Business name*

Your full name*

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Have you opened any new locations in state or out-of-state?*

Yes

Where?*

Does common control come into play this year?*

Parent-subsidiary Controlled Group
- A parent-subsidiary controlled group exists when one or more chains of organizations are connected through ownership of a controlling interest with a common parent organization if:
  - A controlling interest in each of the organizations (except the common parent) is owned by one or more of the other organizations in the group; and
  - The common parent organization owns a controlling interest in at least one of the other organizations.
Brother-sister Controlled Group
- A brother-sister controlled group exists when five or fewer individuals, estates or trusts own a controlling interest (80 percent or more) in each organization and have effective control. “Effective Control” generally means 50 percent of the organization’s stocks and profits, but only to the extent that the ownership is identical with respect to each organization.
Combined Controlled Group
- A combined control group exists if three or more organizations are structured in the following way:
- Each organization is either a member of a parent-subsidiary or brother-sister controlled group; and
- At least one organization is the common parent organization of a parent-subsidiary controlled group and is also a member of a brother-sister controlled group.

Yes

Common Control Companies*

Name of the company

Amount of employees

Interested in offering more than 1 medical plan?*

Can offer 2 or 3 plans depending on the size of group.

Yes

What types of plans would you like to see along side w/ your current plan*

HMO

PPO

HAS

Interested in any ancillary coverages?*

check all that apply

Group Dental

Group Vison

Short Term Disability

Long Term Disability

Group Life

Happy with your current plan?*

Yes

What type of alternatives are you interested in?*

Deductible options

Co-insurance options

Copay options

Plan type options – H.S.A.?

Anything to lower monthly premium

Would you like more information on:*

Medicare Insurance

Commercial Insurance

Group & Voluntary Benefits

Individual Life Insurance

Personal Health Insurance

Annuities & Financial Services

Other

What other information interests you?*

Medicare Policy Renewal

"*" indicates required fields

Business Name*

Insured Name*

Email*

Phone*

Mailing address*

Street Address Address Line 2 City State ZIP Code

Verify what Medicare plans, what coverage do you have now?*

What do you like about your current coverage?*

What would you add/alter to make your coverage better?*

Any particular ways you use your coverage that I should be aware of?*

Do have any preference on the network of plans:*

HMO

PPO

No Preference

Do you make your plan decision or does someone help you make your decisions?*

I make my own

Someone else

Who helps you with the descision*

Would you like me to check if any of your current doctors are in-network?*

Yes

Name of Doctor’s office and location*

Click on the plus sign to add additional fields

Would you like me to check if your Rx drugs are covered and at what cost?*

Yes

List*

Name of the drug

Dose size

Click on the plus sign to add additional fields

Current Pharmacy used?*