Business Insurance Form

Business Insurance Form

Please complete the information to the best of your ability, so that we can provide you with the best valued market estimates and coverage recommendations!
Today's Date

MonthDayYear
Date
How did you hear about us?
What is the referring person's Name?
Name
Name of Business

Entity NameDBA
Entity Type
Other Type
Business Owner's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
How many years experience do you have in this same field of work?
Do you have a Partner or Spouse you are working with?

YesNo
Business Partner / Spouse Name

First NameLast Name
When did the Business Start?

MonthDayYear
Date
What services or products does the business provide?
Does the business have a website?

YesNo
What is the Website Address?
Does the Business have property and/or equipment?

YesNo
What amount of personal property and/or equipment would you like to insure for?
Is this a home based business or is there a physical business location?

Home BasedPhysical Business Location
Have you or will you put money into the build out or permanent additions and built ins of the physical space? (Ex: Floors, Paint, Built in reception, divisions, counter, etc.)

YesNo
How much have you spent or will you spend on the build out of the physical space?
What are the projected Annual Revenues?
Does the business have any prior Insurance?

NoYes
What is the Prior Carrier Name?
Reason for Shopping?

New in BusinessPolicy Cancelled/LapsedNon Renewal due to Carrier no longer writing in state or productNon Renewal due to Loss HistoryPremium IncreaseCoverageServiceOther
More details:
Has the business had any losses in the last 5 years?

YesNo
For each loss: What happened? What was the date of the loss? How much was paid? Is the loss still open or closed now?
Are you looking to secure only premises liability (slip and fall) to satisfy a lease or would you like to secure business liability to protect the actual business operations as well?

Premises only to satisfy a leaseBusiness Operations
Who are the businesses top 5 clients and the percent revenue from each?
Total Annual Payroll or Projected Payroll?
Does the business have or will have W2 Employees?

YesNo
How many Part Time?
Total Part Time Projected Payroll?
How many Full Time?
Total Full Time Projected Payroll?
Does the business have any or will have any 1099 U.S. Employee Payroll?

YesNo
What is the total 1099 U.S. Employee projected payroll?
Do you currently have a Worker's Compensation Policy?

YesNo
Are you open to seeing a Workers Compensation quote as well?

YesNo
Are there any leased employees?

YesNo
Do all employees have the same role/duties/positions?

YesNo
Describe what they physically do? If Multiple roles: Class Types (Roles), # of Employees in each role, & Total Payroll for each role
Do any of the Employees (W2 or U.S. 1099) work remotely from home?

YesNo
Which Employees and what are their U.S. Home Addresses?
What are the Owners/Officers/Members Names?
How much of the W2 Payroll is the Owner's Payroll?
Do you want to exclude or include workers compensation coverage for the owners?

ExcludeInclude
Have you had any Work Comp Losses in the last 5 years?

YesNo
Described what happened? The approximate date? How much was paid? Is the claim still open or closed now?
What is the business tax ID (FEIN)?
Does the business own/need Commercial Autos?

YesNo
Vehicle List: VIN #s, Year, Make & Model, Vehicle BODY TYPE, & Garaging Addresses for each vehicle?
Driver List: First & Last Names, DOB, DL#, Married/Single, Which vehicle they drive?
What is the Business Mailing Address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this the same as the Physical Business Address?

YesNo
What is the Physical Business address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you own or lease building / space?

LeaseOwn
What is the square footage of the space you occupy?
Square Feet
Is the Entity that operates the business the same Entity that owns the Building?

YesNo
Do you need the building insurance as well or is that already covered?

Yes, also need Building InsuranceNo, it is covered at this time. Just shopping the business operations part.
Copy and Paste the link below in another browser window to also complete the information we will need to insure the building, and submit both forms.
https://form.jotform.com/240424479499166
Contact Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
This form was completed by:

First NameLast Name
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