Insurance Program Questionnaire
Company Name:
Company Address:
Telephone:
 Email Address:
Contact Name:
As a business owner, what are:
1.Your long term goals:
2. Do you have any plans for growth in the future,
either by acquisition or adding to your work force:
3. What are your current priorities:
4. Do any of your plans include lowering your insurance costs, to free
up cash flow to help you expand, and if so how will you achieve this:
Yes
5. Does your current Broker offer comprehensive, loss and safety programs:

5a. If so does your current insurance carrier offer credits based on these programs:
 No
Yes
No
6. Do you base your choice of Brokers based on the best price every year,
by price shopping or by the Brokers services offered:
7. Would you like a free review of your current policies and programs, and receive
our recommendations: