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Commercial Insurance Questionnaire
General Informations
Company Name
*
Applicant Name
*
First Name
Last Name
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
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Legal Entity
Corporation
Partnership
Individual
LLC
Business Established Date
-
Month
-
Day
Year
Date
FEIN
*
Detailed information about your business
*
Business Hours
*
Insurance coverage requested
*
Business Owner Policy (BOP)
General Liability
Professional Liabilty
Property
Workers' compensation
Number of Owners
Number of Employees
Gross Annual Payroll ($) Excluding owner
*
Owner Gross Payroll ($)
*
Gross Annual Revenue ($)
*
Desired Effective Date for New Policy
-
Month
-
Day
Year
Date
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Losses / Claims
Any claims within 5 years
Yes
No
Explanation
Business Owner Policy
Do you sell alcohol
Yes
No
Sales receipts from alcohol
Alcohol License Number
Do you have sprinkler
Yes
No
Building Security
Rows
Local
Central
None
Fire Alarm
Burglar Alarm
Workers' Compensation
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)
File Upload: Driver License and Previous Policy
*
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