1. Have there been any significant changes in the following (auditable) areas:

  SALES?
YES
NO

  PAYROLL?
YES
NO

  OTHER?
YES
NO

2. Have you acquired, leased, or rented any:

  REAL ESTATE?
YES
NO

  VEHICLES?
YES
NO

  WATERCRAFT?
YES
NO

  MOBILE EQUIPMENT?
YES
NO

  OTHER EQUIPMENT?
YES
NO

3. Have you entered into any written or informal agreement with contractors, suppliers, customers, unions, or others?

YES
NO

4. Have you made any changes in corporate structure or partnerships or had new acquisitions?

YES
NO

5. Do you perform work and/or have locations outside the state of Indiana?

YES
NO

If YES, enter States (format: OH/IL/KY)

6. If applicable, please list approximate value of:

                Building(s)
           Contents/Inventory
Business Personal Property
  Lease Hold Improvements
           Specialty Equipment

7. Have your operations changed from those listed in your policy?

YES
NO

8. Have you had any service problems with our agency or the insurance company?

YES
NO

9. Are there any issues you would like to discuss with us?

YES
NO

               Name:

Business Name:

          Phone #:

  Email Address:

                 Date: (format: DD/MM/YYYY)