Annual Insurance Checklist

Name: Dombrowski Insurance Agency
Address: 3093 Washington Pike, Bridgeville, PA, 15017, US
Telephone: (412) 257-2151

First Name*
Last Name*
Phone*
Email*
Which type of insurance do you have with us? Select all that apply.*
- Personal Insurance
- Business Insurance
Personal Insurance
Home Address
Street Address Address Line 2 City State ZIP Code
Have you renovated, remodeled, added on to, or otherwise updated your home(s)?
- Yes
- No
Have you started a business based out of your home?
- Yes
- No
Do you protect your home with a professional security system?
- Yes
- No
Have you added a permanent swimming pool?
- Yes
- No
Do you or any family members perform babysitting services in your home?
- Yes
- No
Do you employ any part-time or full-time domestic help, including nannies, housekeepers, or landscapers?
- Yes
- No
Have you purchased any additional residences such as condos, timeshares, or second houses?
- Yes
- No
Do you rent out your home as part of the home-sharing economy?
- Yes
- No
If you’ve started renting out your home or any other property, do you have renters insurance?
- Yes
- No
Are all of your vehicles, including recreational vehicles and watercraft, insured with this agency?
- Yes
- No
Have you recently purchased any additional automobiles, recreational vehicles, or watercraft?
- Yes
- No
Have you upgraded any of your vehicles with new equipment?
- Yes
- No
Do you need to add any new drivers to your policy?
- Yes
- No
Do you drive any employer-sponsored vehicles?
- Yes
- No
Do you own any older vehicles that may be classic or collector cars?
- Yes
- No
Do you provide ride services as part of the ridesharing economy?
- Yes
- No
Do you have any children who no longer live at home and can no longer be considered dependents?
- Yes
- No
Have you purchased any jewelry, electronics, or other valuables that you would like to add to your policy?
- Yes
- No
Are there any such items that you would like to change or remove from your policy?
- Yes
- No
Do you insure your personal possessions for their full replacement value?
- Yes
- No
Have you recently added or otherwise changed ownership of assets such as trusts, titles, or LLCs?
- Yes
- No
Are there any other insurance coverage issues you would like to discuss?
- Yes
- No
Business Insurance
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Total Number of Employees
Are there any business properties or pieces of equipment that you have recently acquired, leased, or sold?
- Yes
- No
Have you closed or opened any business locations?
- Yes
- No
Has your company building undergone any renovations, additions, or other significant changes?
- Yes
- No
Have you added, changed, or removed any company products?
- Yes
- No
Has your inventory level experienced any significant shifts or fluctuations?
- Yes
- No
Do you either purchase supplies from or sell your products to foreign countries?
- Yes
- No
Has the ownership structure of your business changed?
- Yes
- No
Has there been a 10% or greater change in your business's revenue in the last year?
- Yes
- No
Do 50% or more of your materials come from a single supplier?
- Yes
- No
Do 50% or more of your sales come from a single buyer?
- Yes
- No
Do any of your employees regularly work from home or from another state?
- Yes
- No
Do any of your employees regularly travel to other states or countries for business?
- Yes
- No
Do any of your employees travel for business in their personal vehicles?
- Yes
- No
Has your company leased, purchased, or sold any automobiles or other vehicles?
- Yes
- No
Do you require all vendors, subcontractors, and 1099 workers to provide certificates of insurance?
- Yes
- No
Are there any other insurance coverage issues you would like to discuss today?
- Yes
- No
Name
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Dombrowski Insurance Agency

3093 Washington Pike
Bridgeville, Pennsylvania 15017

Phone: (412) 257-2151

Fax: (412) 257-8213

Mon-Fri: 9:00am-5:00pm
Sat-Sun: Closed

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Dombrowski Insurance Agency specializes in Auto/Car Insurance, Homeowners Insurance, Business/Commercial Insurance, and Life Insurance to all of Pennsylvania, including Bridgeville, South Fayette Township, Carnegie, Cecil, Canonsburg, Lawrence, Scott Township, Upper St. Clair, Mt. Lebanon, and Pittsburgh.

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