Insurance Assessment
 

Required fields in bold

What activity is your business most
 involved in?: 


 

 Providing professional business services
Manufacturing products

 		 Wholesaling goods or
supplying parts
Providing legal services
Offering financial services
Broadcasting or telecommunications
Retailing goods to consumers

How many employees do you have?: 

 0-10
11-100
101-749
750+
Does your business or organization have a web site?:  Yes
No
Do you use your web site to directly generate business income for your products or services?:  Yes
No
Do you use your web site to collect information
from clients?: 		 Yes
No
Do you store critical business data electronically:  Yes
No
Do you store confidential information of others electronically?:  Yes
No
Do you perform background checks on new employees, vendors and/or consultants who do work for you?:  Yes
No
 
Full Name: 
Company Name: 
E-mail Address: 
Street Address: 
City: 
State: 
Zip: 
Phone Number: 
Fax Number: 
Comments: 
 

 




 
221 S. Hamilton Rd., Columbus, OH 43213 | Phone: (614) 236-8691
© 2006 Aardvark Insurance