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Our goal is to work with you to identify any areas that you feel are critical to you and your company.  Next, we evaluate if RJF can play a role in being a resource in addressing those areas going forward. 

In order to help us with this process, please read the following high-level statements surrounding different areas of your risk management program.  

Indicate the level to which you agree or disagree with the statement
(Check a level between 1-4:  1 = you “strongly disagree”, 4 = you “strongly agree”) 
Then indicate how important that particular statement is to you
(Check a level between 1-4:  1 = “not important”, 4 = “extremely important”)

First Name:
Last Name:
Title:
Company:
# of EE's:
Industry:	--Choose Industry-- Agriculture Co-ops Auto Dealers Construction/Contractors Hospitality Manufacturing & Distribution Retail Small Businesses Townhome/Condo Association Other Please Describe:
Phone:
Email:
Please follow-up with me by:
Phone   Email
I have a meeting already scheduled with (please include first and last name):

1)	Our management team understands what are greatest risks are within our organization.
	1 Strongly Disagree	2 Disagree	3 Agree	4 Strongly Agree
	How Important is this to you?
	1	2 3		4
	Not Important	Somewhat Important		Extremely Important
2)	We have an effective risk management program to manage our cost of risk.
	1 Strongly Disagree	2 Disagree	3 Agree	4 Strongly Agree
	How Important is this to you?
	1	2 3		4
	Not Important	Somewhat Important		Extremely Important
3)	Our management team has a “long-term” strategy to control our cost of risk.
	1 Strongly Disagree	2 Disagree	3 Agree	4 Strongly Agree
	How Important is this to you?
	1	2 3		4
	Not Important	Somewhat Important		Extremely Important
4)	We have a complete understanding of our risks and our program is competitive in comparison to similar companies in our industry.
	1 Strongly Disagree	2 Disagree	3 Agree	4 Strongly Agree
	How Important is this to you?
	1	2 3		4
	Not Important	Somewhat Important		Extremely Important
5)	Our company's exposures are being effectively managed at every level of our organization.
	1 Strongly Disagree	2 Disagree	3 Agree	4 Strongly Agree
	How Important is this to you?
	1	2 3		4
	Not Important	Somewhat Important		Extremely Important
6)	Our risk management vision is clearly communicated to all employees.
	1 Strongly Disagree	2 Disagree	3 Agree	4 Strongly Agree
	How Important is this to you?
	1	2 3		4
	Not Important	Somewhat Important		Extremely Important
7)	Our employees have an understanding how safety activities and claims affect our bottom line.
	1 Strongly Disagree	2 Disagree	3 Agree	4 Strongly Agree
	How Important is this to you?
	1	2 3		4
	Not Important	Somewhat Important		Extremely Important
8)	Our employees believe that we have a strong risk management culture.
	1 Strongly Disagree	2 Disagree	3 Agree	4 Strongly Agree
	How Important is this to you?
	1	2 3		4
	Not Important	Somewhat Important		Extremely Important
9)	Our company has an effective safety program to reduce losses.
	1 Strongly Disagree	2 Disagree	3 Agree	4 Strongly Agree
	How Important is this to you?
	1	2 3		4
	Not Important	Somewhat Important		Extremely Important
10)	I am comfortable with the information I receive from my broker to understand how our overages are priced.
	1 Strongly Disagree	2 Disagree	3 Agree	4 Strongly Agree
	How Important is this to you?
	1	2 3		4
	Not Important	Somewhat Important		Extremely Important
11)	Our carrier / broker provides our company regular claims status updates.
	1 Strongly Disagree	2 Disagree	3 Agree	4 Strongly Agree
	How Important is this to you?
	1	2 3		4
	Not Important	Somewhat Important		Extremely Important
12)	We have control over our property & casualty insurance program.
	1 Strongly Disagree	2 Disagree	3 Agree	4 Strongly Agree
	How Important is this to you?
	1	2 3		4
	Not Important	Somewhat Important		Extremely Important
	ADDITIONAL COMMENTS (please include any comments that you feel we should be aware of surrounding your risk management program):
	*Please type the following text in the text box below (case sensitive):