Commercial Insurance Questionnaire
General Business Information
Contact Name
*
First Name
Last Name
Email
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Company Name
*
Include any DBA's
Legal Business Entity
*
Nonprofit
Corporation (Inc. / Co. / Corp.)
Partnership (LLPs)
Individual
LLC
Other
Business established date
*
-
Month
-
Day
Year
Date
FEIN
*
Federal Employer Identification Number
Number of Employees (Do Not Include Owners or Executives):
Indicate Full-Time or Part-Time for Each
What services or products do you provide?
*
Detailed information about your business services, products or procedures
Annual Gross Revenue ($)
Gross Annual Employee Payroll
Do not include Owner(s) salaries
Sub-Contractor Payroll
Annual Payroll Paid to Subs
Insurance coverage requested
General Liability
Commercial Auto
Business Owner Policy (BOP)
Professional Liability / Errors & Omissions (E&O)
Workers' Compensation (Work-Comp / Workman's Comp)
Other
Current Insurance Carrier
Write NONE if lapse is greater than 45 days
Current Policy Expiration Date
-
Month
-
Day
Year
Date
Desired Effective Date for New Policy
-
Month
-
Day
Year
Date
Back
Next
PROPERTY DETAILS
SKIP if you do not need coverage for the office/building/storefront
Are you requesting Property Coverage
Yes
No
Building Information
Construction Type
Please Select
Masonry - Concrete Block, Brick, Stone
Non-combustible - Metal Frame
Heavy Timber
Wood-Framed w Vinyl Siding
Wood-Framed w Stucco Siding
other
Year Built
Insured sq feet
Year Renovated or Updated
Renovated Year
Roof
Electrical
Plumbing
Heating
Building Security
Local
Central
None
Fire Alarm
Burglar Alarm
Building Value ($)
Cost to Replace or Rebuild the Building
Property or Contents Value ($)
Inventory, Tools & Equipment
Back
Next
GENERAL LIABILITY
Are you requesting General Liability Coverage
Yes
No
Desired Amount of General Liability Coverage ($)
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?
Back
Next
Professional Liability
Are you requesting Professional Liability Coverage?
Yes
No
Desired Amount of Professional Liability Coverage ($)
Describe Professional Services offered?
Does your firm provide services outside the U.S.?
Yes
No
Percentage of Services for the outside the U.S
Is there a formal Safety Plan?
Yes
No
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
What is the percentage of your firm’s gross Fees paid to ICs or Sub Contractors last year?
Yes
No
Do you request Certificates of Insurance from ICs and Sub Contractors?
Do you have written agreements on every project?
Do ICs and Sub Contractors have written agreements?
Do you provide Professional Liability to your ICs and Sub Contractors?
Back
Next
Medical Professional Liability
Are you requesting Medical Professional Liability Coverage?
Yes
No
Desired Amount of Professional Liability Coverage ($)
Describe Professional Services offered
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
Yes
No
Do you employ Physicians or Surgeons?
Is there a Medical Director?
Does the Medical Director have their own insurance?
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?
Do you bill for Medicare/Medicaid?
Back
Next
Workers' Compensation
Are you requesting Workers’ Compensation Coverage?
Yes
No
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?
Yes
No
Do you offer Paid Vacation?
Yes
No
Is there a formal Safety Program?
Yes
No
Total Payroll ($)
Submit
Should be Empty: