GJIG Commercial Insurance Discovery Form

Commercial Insurance Application
General Business Information
What is the full name of your business?
Submitted By:*

YOUR First NameYOUR Last Name
Your Email*
example@example.com
Your DOB

MonthDayYear
Date
Your Phone*
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?*

ReferralGoogle SearchSocial PostOther
Referred By Person info: Please put their name and email below so we can thank them!

First NameLast Name
Referred By Email
example@example.com
Prospect Information
Company Name*
Main Contact Name

First NameLast Name
Role
Role / Position at the Company
Main Contact Email
example@example.com
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Company Website
If Applicable
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What Type of Policies Would You Like? (click all that apply)

Business Owners Policy (BOP)General LiabilityWorker's CompensationCommercial AutoCyber Liability (Standalone)Motor Truck CargoMisc. Professional LiabiltySurplus Lines - PropertySurplus Lines - General LiabilityUmbrella Liability / Excess LiabilitySpecial Events
Business Information
FEIN#
Entity Type*
Year Business Established*
Industry
NAICS Code
If Known
Years of Industry Experience*
What Does Company Do?
General Overview
Number of Full Time Employees
Number of Part Time Employees
Number of Subcontractors
Annual Payroll
For Entire Payroll
Worker's Comp Payroll Code
If Known
Gross Sales
Most Recent Year
Any 24 Hour Operations?

YesNo
Hours of Operation
Amount of Business Personal Property Coverage
$ Amount
DOT #
If Applicable
If requesting COMMERCIAL AUTO, please include locations below where vehicles are garaged
Garaging Address
How Many Total Vehicles
Include Cars, Trucks, Trailers, Etc.
Business Use Class

ServiceRetailCommercialOther
Auto Liability Limit
$ Amount
How Many Cars
Cars Only
How Many Trucks
Trucks Only
Truck Body Type

BusCatering TruckMini VanPick UpStep VanUtility VanSemiOther
Gross Vehicle Weight (in lbs)
How Many Trailers
Trailers Only
Add Hired & Non-Owned Auto Liability Coverage?

YesNo
Are Any of the Vehicles Leased to Others?
Yes / No
Radius Class
Percentage of Driving Under 50 Mile Radius
Percentage of Driving Within 51-200 Mile Radius
Percentage of Driving Within 201-500 Mile Radius
Percentage of Driving over 500+ Mile Radius
Do You Require MVR Verification for Drivers

YesNoOther
How Many Locations?

1234Other
If Multiple Locations, Please List Additional Locations Below:
Addresses of additional locations
Building Property Owned or Leased?

OwnedLeasedSubleased
If Owned, is there a mortgage and if so, who is lender?
Please answer both questions above
When Did You Purchase the Property?
Approximate Year
Total Building Square Footage
Entire Building SF
Occupied Square Footage
SF Business Occupies
Building - Year Built
Building - # of Stories
Construction Type
Frame, Masonry, Pre-Cast, etc.
Sprinkler System?

YesNoOther
Type of Smoke Detectors
Does Your Operation Have Rack Storage 12 Feet or Higher?

YesNo
Any Alcohol Sales?

YesNo
Who Manages the Property?

SelfThird Party Professional Property Management CompanyNoneOther
If 3rd Party Property Management Company, Name of Company
Name of the Property Management Company
Any Updates to Building (if owned)?
Heating, Plumbing, Electrical, Roofing, Etc.
Do You Have Coverage Currently?*

YesNo
If NO current insurance, please explain:
Reasoning: New Venture - Cancelled - Lapse - etc.
Current Insurance Carrier *
Years with Current Carrier
# of Years
Current Insurance Premium
Current Insurance Expiration

MonthDayYear
Date
If YES above, please attach your current declaration pages, loss runs, and any other insurance documentation

Cancelof
Any Losses? If Yes, explain in "Other"*

NoYesOther
Any Other Info We Should Know:
Additional File Upload

Declaration Pages, Loss Runs, List of Commercial Vehicles / Drivers, etc.
Cancelof
Should be Empty:

Commercial Insurance Application

General Business Information

Prospect Information

Business Information