Complete Annual Renewal

Client Information
Your Name*
First Last
Your Email*
Your 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.

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.

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.

Additional Protection
We're a full service agency providing solutions for personal, business, employee benefits and specialty Insurance needs for our clients.
Would you like to discuss any additional insurance protection with our firm?*
- Yes
- No
Confirmation
Your initials*
For your safety and security, please do not submit any sensitive financial, personal, or protected health information on this form. This information should be provided directly to a Main Street team member.
This field is for validation purposes and should be left unchanged.

It’s time to review your insurance.