A Division of C.H. Insurance Brokerage, Inc.www.chinsurance.cc
* Denotes Required Fields
During the past 5 year has the name of the firm been changed or has any other business(es) been acquired, merged into or consolidated with the agency?
Provide a Breakdown of the Agency’s staff into the following categories:
What percentage of the Agency’s gross revenues is derived from:
Provide the percentage of the Agency’s gross annual revenue from the last fiscal period attributable to the following:
Dates of the Agency‘s fiscal period:
Total Gross Annual Revenue
Past Fiscal Year
Current Fiscal Year
Does the Agency secure a written contract or agreement for every project?
Please attach a sample copy
If no, provide the percentage of your gross annual revenue where a written contract is secured:
Does the Agency's contract contain any of the following? (Check all that apply)
List the top four clients you have contracted with over the past (12) months and annual billing
Was more than 50% of the agency’s total gross billing from any one year derived from a single contract?
Has any similar insurance on your behalf ever been declined, canceled or renewal refused?
Does your agency currently carry commercial general liability insurance?
If yes please provide:
Does your agency currently carry Professional liability (E&O) insurance?
Have any claims, suits or demands for arbitration been made against the agency, its predecessor(s) or any past or present principal, partner, officer or employee within the past 5 years?
Are you working from home or office?
If an office, provide details:
Recommend DHH Insurance