COMMERCIAL INSURANCE QUOTE FORM
General Information
Applicant Name
First Name
Last Name
Email
example@example.com
Contact Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Name
Legal Entity
Nonprofit
Corporation
Partnership
Individual
LLC
Other
Business established date
-
Month
-
Day
Year
Date
FEIN
Number of employees
Detailed informations about your business
Gross Annual Payroll ($)
Gross Annual Revenue ($)
Insurance coverage requested
Business Owner Policy (BOP)
Commercial Auto
General Liability
Professional Liabilty
Workers' compensation
Other
Current Insurance Carrier
Current Policy Expiration Date
-
Month
-
Day
Year
Date
Current Policy Retroactive Date
-
Month
-
Day
Year
Date
Desired Effective Date for New Policy
-
Month
-
Day
Year
Date
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PROPERTY DETAILS
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
Renovated Year
Roof
Electrical
Plumbing
Heating
Building Security
Local
Central
None
Fire Alarm
Burglar Alarm
Building Property Value ($)
Building Property Value ($)
Building Property Value ($)
Personal Property Value ($)
Annual Gross Revenue ($)
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GENERAL LIABILITY
Are you requesting General Liability Coverage
Yes
No
Desired Amount of General Liability Coverage ($)
Type a question
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 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?
Type a question
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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Commercial Auto
Are you requesting Commercial Auto Coverage?
Yes
No
Please fill out the vehicle schedule below. If you have more than 10 vehicles. Attach a vehicle schedule spreadsheet at the end of the application.
Make and Model
Vin Number
Comp?
Collision?
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Vehicle 6
Vehicle 7
Vehicle 8
Vehicle 9
Vehicle 10
Do any employees use their personal vehicles for business use?
Yes
No
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Inland Marine
Are you requesting Inland Marine insurance?
Yes
No
Please fill out the Equipment Schedule below listing your large equipment such as Forklifts, Dozers, Skid Steer ETC. If you have more than 10 please attach a spreadsheet at the end of the application.
Make and Model
Serial Number
Garaging location?
Equipment 1
Equipment 2
Equipment 3
Equipment 4
Equipment 5
Equipment 6
Equipment 7
Equipment 8
Equipment 9
Equipment 10
For Contractors: What is the average size of your typical job?
For Contractors: What is your largest job over the last 12 months?
For Contractors: What is the value of all other tools and equipment not listed in the schedule above? Hammer, Drill, Levels ETC.
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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 Estimated Payroll ($)
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Commercial Umbrella
Are you requesting a Commercial Umbrella?
Yes
No
What limit are you interesting in buying?
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Please select any and all other coverages you either currently have or are interested in seeing quotes for.
Currently insured
Would look at a quote
I have never heard of this before
Errors and Omissions
Director's and Officer's
Employment Practices Liability
Kidnap and Ransom
Pollution
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Please attach the following documents for review.
Current copies of your insurance polcies. General Liaiblity / Commercial Auto / Workers Compensation ETC.
At least three years loss history.
Pictures of any buildings to be insured.
Any other requested documents in the application.
Please attach files below
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What is most important to you and your business regarding your insurance plan & broker? 1 being least 4 being most important.
1
2
3
4
Price
Service
Support
Relationship
Dedicated Account Manager
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