Commercial Insurance Questionnaire
General Information
Applicant Name
First Name
Last Name
Date of Birth
MM/DD/YYYY
Email
example@example.com
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Name
Business Address (If dIfferent from Home Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Entity
Nonprofit
Corporation
Partnership
Individual
LLC
Other
Business established date
-
Month
-
Day
Year
Date
FEIN if you have one
Number of employees
Detailed information about your business- what you sell, equipment you use and need covered, do you sell online, at in-person events etc?
Gross Annual Revenue ($)
Insurance coverage requested
Business Owner Policy (BOP)
Commercial Auto
General Liability
Professional Liabilty
Workers' compensation
Other
Current Insurance Carrier or N/A
Current Policy Expiration Date
-
Month
-
Day
Year
Date
How many years have you had a business policy?
Desired Effective Date for New Policy
-
Month
-
Day
Year
Date
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GENERAL LIABILITY
Are you requesting General Liability Coverage
Yes
No
Desired Amount of General Liability Coverage ($)
$1 Million per occurence is standard unless other amount is requested! $2 Million aggregate is common unless otherwise requested.
Underwriting Questions
Rows
Yes
No
Are any autos used exclusively for business use?
Do any employees use a personal auto for business use?
Are any web based services offered?
Are credit card payments accepted?
Is there a program to identify identity theft?
Is there Underground Tank Leakage Exposure?
Is there a Pollution Exposure?
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Professional Liability
For Service Based Businesses
Are you requesting Professional Liability Coverage?
Yes
No
Desired Amount of Professional Liability Coverage ($)
Describe Professional Services offered?
Does your firm provide services outside the U.S.?
Yes
No
Percentage of Services for the outside the U.S
Is there a formal Safety Plan?
Yes
No
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
What is the percentage of your firm’s gross Fees paid to ICs or Sub Contractors last year?
Rows
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?
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PROPERTY DETAILS
SKIP IF HOME BASED or ONLINE ONLY BUSINESS
Are you requesting Property Coverage
Yes
No
List the current carrier
Building Information
Construction Type
Please Select
fire-resistive
non-combustible
ordinary
heavy timber
wood-framed
other
Year Built
Insured sq feet
Unoccupied sq feet
Year Renovated
Rows
Renovated Year
Roof
Electrical
Plumbing
Heating
Building Security
Rows
Local
Central
None
Fire Alarm
Burglar Alarm
Building Property Value ($)
Building Property Value ($)
Building Property Value ($)
Personal Property Value ($)
Annual Gross Revenue ($)
Workers' Compensation
Only for businesses with employees
Number of Employees
Rows
Full-time
Part-time
Number of Employees
Number of Independent Contractors (ICs)
Rows
Full-time
Part-time
Number of Independent Contractors (ICs)
Are Medical Benefits Offered?
Yes
No
Do you offer Paid Vacation?
Yes
No
Is there a formal Safety Program?
Yes
No
Total Estimated Yr Payroll $
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Commercial Auto Information if Applicable
Vehicles owned for the business
Year, Make and Model of Vehicle #1
VIN of Vehicle #1
Year, Make and Model of Vehicle #2
VIN of Vehicle #2
Names, Date of Births and Drivers License numbers for all drivers
Current Commercial Auto Insurance Carrier
Coverage Limits
Current Policy Expiration Date
-
Month
-
Day
Year
When policy is due for renewal
How many years with current carrier?
Please Select
1-2 years
2-3 years
3-4 years
4-5 years
5+ years
Any claims or moving violations in the last 5 years?
No
Yes
If yes to claims or moving violations, please provide date and explanation below
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I agree to review the privacy policy available at www.ramertinsurance.com. Please select yes to accept communications via email, phone call or text message including marketing, account updates or general communications. You may opt out at any time by replying stop or unsubscribing. We do not sell or share your information with any unauthorized parties.
*
Yes
No
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