COMMERCIAL INSURANCE RESEARCH FORM
General Information
COMPANY FULL NAME (and/or D.B.A.)
FEIN(OR OWNER SS#
*
Legal Entity
Nonprofit
Corporation
Partnership
Individual
LLC
Other
Applicant Name
First Name
Last Name
Email
example@example.com
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of employees
Current Policy Expiration Date
-
Month
-
Day
Year
Date
Insurance coverage requested
Business Owner Policy (BOP)
Commercial Auto
General Liability
Professional Liabilty
Workers' compensation
Other
Desired Effective Date for New Policy
-
Month
-
Day
Year
Date
Nature of Business
Please Select
Apartment
Contractor
Manufacturing
Restaurant
Service
Condominiums
Institutional
Office
Retail
Whole Sale
Details about your business operations
Current Insurance Carrier
Gross Annual Payroll ($)
Gross Annual Revenue ($)
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Is there currently coverge for this insurance you are applying for in effect. (It is OK if you are uninsured at this time. We are brokers that can help with this)
Please Select
Business established date
-
Month
-
Day
Year
Date
PROPERTY DETAILS
Are you requesting Property Coverage for a building or space you own or rent? (IF NOT YOU MAY SKIP TO PAGE 3)
Yes
No
List the current carrier
Building Information
Premises Address#:
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 Limit ($)
Personal Property Value ($)
Annual Gross Revenue ($)
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GENERAL LIABILITY
Are you requesting General Liability Coverage
Please Select
Yes
No
Coverage Limit:
Rows
Limits $
General Aggregate
Product & Completed Operations Aggregate
Personal & Advertising Injury
Each Occurrence
Damage to Rented Premises
Medical Expense
Other Coverage, Restrictions AND/OR Endorsements
Schedule of Hazards
Rows
Loc#
Classifications
Class code
Exposure
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
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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Workers' Compensation
Are you requesting Workers’ Compensation Coverage?
Please Select
Yes
No
Effective date
-
Month
-
Day
Year
Date
Location address:
Rows
Limits $
Each Accident
Disease - Policy limit
Disease-Each Employee
Number of Independent Contractors (ICs)
Rows
Full-time
Part-time
Number of Independent Contractors (ICs)
Individual Include/Excluded
Rows
State
Loc#
Name
DOB
Ownership %
Inc/Exc
Type a question
Rows
Location 1
Location2
Location 3
Class code
Classifications
Full Time #Employee
Part Time #Employee
Payroll
Are Medical Benefits Offered?
Yes
No
Do you offer Paid Vacation?
Yes
No
Is there a formal Safety Program?
Yes
No
Total Estimated Payroll ($)
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Commercial Auto
Coverage Limits
Rows
Limits
Lability Limits
Medical Payment
Uninsured/Underinsured Motorist
Hire Auto
Non-Owned Auto
Comp/Coll
List of Vehicles
Rows
Vehicle 1
Vehicle 2
Year
Make
Model
VIN#
Drivers List
Rows
Driver 1
Driver 2
Full Name:
Date of Birth:
License Number:
Lic State:
Sex:
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