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AXIS Capital
AXIS Express Renewal Questionnaire
Has your company name changed or has your ownership structure changed?
No
Yes
What are your projected revenues?
*
Please enter a value
Do you anticipate any significant changes in your operations in the upcoming year?
No
Yes
Has your staff increased by more than 10%?
No
Yes
Are you considering or have you filed for bankruptcy in the past year?
No
Yes
Are you operating in any new states versus last year?
No
Yes
Are you seeking different limits of liability or deductibles than your expiring policy?
No
Yes
Are you seeking any changes in coverages, terms, or conditions?
No
Yes
Are you aware of any claims, incidents, or circumstances that you have not reported?
No
Yes
The undersigned authorized representative of the Insured declares that the statements set forth herein are true. The undersigned authorized representative agrees that if the information supplied on this questionnaire changes between the date of this questionnaire and the effective date of the insurance, they shall, in order for the information to be accurate on the effective date of insurance, immediately notify the Insurer of such changes. The statements and answers made in this questionnaire are true to the best of my knowledge. I have neither omitted nor misrepresented any information.
Check this box to agree
*
Full Name
*
Email Address
*
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