Commercial Auto Insurance Questionnaire
Business Information
Applicant name
*
First Name
Last Name
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal entity name
*
DBA company name
Legal entity
*
Please Select
Sole Proprietorship
Partnership
LLC
Corporation
Nonprofit
Other
Company website
Business established date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of employees
*
Detailed description of business location
*
Example: Retail building, strip mall, executive suite. Include information of neighboring tenants. Include square footage of your unit and building total (estimate ok)
Detailed description of all products sold or services offered
*
How much foot traffic do you get
Percent of online sales
Value of digital records
Business personal property value
Gross annual sales
*
Estimate is ok
Annual payroll
*
Building security
Rows
Local
Central
None
Fire Alarm
Burglar Alarm
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Driver and Vehicle Information
Address of where vehicles are parked/garaged
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Drivers
Rows
Full name
Date of birth
Drivers license number and state
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5
Driver 6
Driver 7
Driver 8
Driver 9
Driver 10
Vehicle 1 VIN
Vehicle 1 Year, Make, Model
Vehicle 1 driving radius
Vehicle 1 permanently attached equipment
Vehicle 1 permanently attached equipment value
Vehicle 2 VIN
Vehicle 2 Year, Make, Model
Vehicle 2 driving radius
Vehicle 2 permanently attached equipment
Vehicle 2 permanently attached equipment value
Vehicle 3 VIN
Vehicle 3 Year, Make, Model
Vehicle 3 driving radius
Vehicle 3 permanently attached equipment
Vehicle 3 permanently attached equipment value
Vehicle 4 VIN
Vehicle 4 Year, Make, Model
Vehicle 4 driving radius
Vehicle 4 permanently attached equipment
Vehicle 4 permanently attached equipment value
Vehicle 5 VIN
Vehicle 5 Year, Make, Model
Vehicle 5 driving radius
Vehicle 5 permanently attached equipment
Vehicle 5 permanently attached equipment value
Vehicle 6 VIN
Vehicle 6 Year, Make, Model
Vehicle 6 driving radius
Vehicle 6 permanently attached equipment
Vehicle 6 permanently attached equipment value
Vehicle 7 VIN
Vehicle 7 Year, Make, Model
Vehicle 7 driving radius
Vehicle 7 permanently attached equipment
Vehicle 7 permanently attached equipment value
Vehicle 8 VIN
Vehicle 8 Year, Make, Model
Vehicle 8 driving radius
Vehicle 8 permanently attached equipment
Vehicle 8 permanently attached equipment value
Vehicle 9 VIN
Vehicle 9 Year, Make, Model
Vehicle 9 driving radius
Vehicle 9 permanently attached equipment
Vehicle 9 permanently attached equipment value
Vehicle 10 VIN
Vehicle 10 Year, Make, Model
Vehicle 10 driving radius
Vehicle 10 permanently attached equipment
Vehicle 10 permanently attached equipment value
Description of non-permanently attached equipment that is transported and estimated total value
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Building Information
Do you require building coverage? *If no, proceed to submit*
Yes
No
Address (If different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Construction type
Please Select
fire-resistive
non-combustible
ordinary
heavy timber
wood-framed
other
Year built
If known
Square footage
*If different from above
Estimated Building Value
Year Renovated (if known)
Rows
Year of Renovation
Roof
Electrical
Plumbing
Heating
Submit
Should be Empty: