CONTACT DETAILS Business Name * Mailing Address * Business Contact * Business Phone * Email Address * Has any of the above information changed or need to be corrected? * YES NO HAVE YOUR GROSS REVENUES INCREASED OR DECREASED OVER THE LAST 12 MONTHS? (PLEASE INPUT MOST UPDATED GROSS SALES NUMBER BELOW) * Yes No GROSS SALES NUMBER Has your company engaged in any new activities or new operations in the past year? * YES NO Have you purchased any new property (e.g., computers, tools, equipment, etc.)? * YES NO Have you purchased or sold any vehicles or trailers? * YES NO Have you made improvements or changes to your existing location(s)? * YES NO Have you moved, added or removed any business location(s)? * YES NO Have you experienced an increase or decrease in staffing? * YES NO Has there been significant growth or cutbacks in business operations? * YES NO Any changes to Mortgage Holders or Leinholders with interest in your Business? * YES NO Do you carry any other business insurance policies other than through Blankenship Insurance? * YES NO COVERAGES OFFERED BY BLANKENSHIP INSURANCE Are you Interested in any of the following Coverages offered by Blankenship Insurance? Data breach/ Cyber Liability Coverage Coverage against employees alleged discrimination, harassment Theft/Crime Insurance Professional Liability Insurance Flood Insurance Umbrella Insurance I would like to be contacted for a complete review of my insurance coverage I would like to be contacted for a complete review of my insurance coverage I would like my insurance policy documents sent via EMAIL. I would like my insurance policy documents sent via EMAIL. Email Address Signature * Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20232024202520262027 *If you are electronically submitting this document , apply your electronic signature to this form by checking the Electronic Signature and acceptance box below. By doing so, you agree that your use of the key pad , mouse or other device to check the Electronic Signature and acceptance box constitutes your signature, acceptance, and agreement as if actually signed by you in writing and has the same force and effect as signature affixed by hand. Electronic Signature and Acceptance - Authorized Representative Electronic Signature and Acceptance - Authorized Representative Leave this field blank
