Insurance Questionnaire

Welcome!
I know the insurance shopping process can be cumbersome and painful. That is why I created this simple online form to replace long PDFs or an hour long Q&A session between us. Please fill this out to the best of your ability. Complete all sections that apply to your business.

Thank you considering USI to represent you in the insurance market. I cant wait to go to work for you.

Regards,

Brock Grabarkewitz

512-955-0566

Brock.Grabarkewitz@usi.com

PROPERTY DETAILS
Are you requesting Property Coverage

YesNo
Building Information
Construction Type
Year Built
Insured sq feet
Unoccupied sq feet

Year Renovated

	Renovated Year
Roof
Electrical
Plumbing
Heating

Building Security

	Local	Central	None
Fire Alarm
Burglar Alarm

Building Property Value ($)
Personal Property Value (Contents) ($)
Annual Gross Revenue ($)

Commercial Auto
Are you requesting Commercial Auto Coverage?

YesNo

Please fill out the vehicle schedule below. If you have more than 10 vehicles. Attach a vehicle schedule spreadsheet at the end of the application.

	Make and Model	Vin Number	Comp?	Collision?
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Vehicle 6
Vehicle 7
Vehicle 8
Vehicle 9
Vehicle 10

Do any employees use their personal vehicles for business use?

YesNo

Inland Marine
Are you requesting Inland Marine insurance?

YesNo

Please fill out the Equipment Schedule below listing your large equipment such as Forklifts, Dozers, Skid Steer ETC. If you have more than 10 please attach a spreadsheet at the end of the application.

	Make and Model	Serial Number	Garaging location?
Equipment 1
Equipment 2
Equipment 3
Equipment 4
Equipment 5
Equipment 6
Equipment 7
Equipment 8
Equipment 9
Equipment 10

For Contractors: What is the average size of your typical job?
For Contractors: What is your largest job over the last 12 months?
For Contractors: What is the value of all other tools and equipment not listed in the schedule above? Hammer, Drill, Levels ETC.

Workers' Compensation
Are you requesting Workers’ Compensation Coverage?

YesNo
Number of Employees

Full-time Part-time

Number of Employees

	Full-time	Part-time
Number of Employees

Number of Independent Contractors (ICs)

	Full-time	Part-time
Number of Independent Contractors (ICs)

Are Medical Benefits Offered?

YesNo
Do you offer Paid Vacation?

YesNo
Is there a formal Safety Program?

YesNo
Total Estimated Payroll ($)

Commercial Umbrella
Are you requesting a Commercial Umbrella?

YesNo
What limit are you interesting in buying?

Please attach the following documents for review.
- Current copies of your insurance polcies. General Liaiblity / Commercial Auto / Workers Compensation ETC.
- At least three years loss history.
- Pictures of any buildings to be insured.
- Any other requested documents in the application.
Please attach files below

Cancelof

	Yes	No
Are any autos used exclusively for business use?
Do any employees use a personal auto for business use?
Are any web based services offered?
Are credit card payments accepted?
Is there a program to identify identity theft?
Is there Underground Tank Leakage Exposure?
Is there a Pollution Exposure?

	Yes	No
Do you request Certificates of Insurance from ICs and Sub Contractors?
Do you have written agreements on every project?
Do ICs and Sub Contractors have written agreements?
Do you provide Professional Liability to your ICs and Sub Contractors?

	Currently insured	Would look at a quote	I have never heard of this before
Errors and Omissions
Director's and Officer's
Employment Practices Liability
Kidnap and Ransom
Pollution

	1	2	3	4
Price
Service
Support
Relationship
Dedicated Account Manager

Welcome!

Commercial Insurance Questionnaire

General Information

PROPERTY DETAILS

Building Information

GENERAL LIABILITY

Professional Liability

Commercial Auto

Inland Marine

Workers' Compensation

Commercial Umbrella

Please attach the following documents for review.