Business Insurance Questionnaire
Tru Family Agency LLC - Farmers Insurance
Business Name
Doing Business As (DBA) / Insured Name
Contact Name & Title
Business Entity Type
Individual
Joint Venture
Partnership
Association
Corporation
LLC
Other
Description of Operations
Years in Business
Years and Months
Years of Management Experience in Business
Years and Months
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Year Built
-
Month
-
Day
Year
Can be found on County Assessor website
Construction Type
Frame
Masonry Non-Combustible
Masonry
Modified Fire Resistive
Non-Combustible
Fire Resistive
Fire Sprinkler System
Yes
No
Building Coverage Amount
How much everything inside building property is worth?
Preferred Deductible
Put "Options" to see all available options.
Preferred Liability Limits
Put "Options" to see all available options.
Number of Full-Time Employees
NOT including Business owner
Number of Part-Time Employees
NOT including Business owner
Total Annual Receipts
Gross Income
Current Insurance
Current Insurance Company & Policy #
Renewal Date
-
Month
-
Day
Year
Expiration Date
Loss History
NONE if no record of losses
Auto Coverage Section
Driver 1 Information
Name
First Name
Last Name
U.S. Drivers License #
State of Issue
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Expiration Date
-
Month
-
Day
Year
International Drivers License?
Yes
No
Auto Coverage Section
Driver 2 Information
Name
First Name
Last Name
U.S. Drivers License #
State of Issue
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Expiration Date
-
Month
-
Day
Year
International Drivers License?
Yes
No
Vehicle 1 Information
(*Required for Medium to Heavy Trucks)
Year / Make / Model / VIN #
Separate cars with commas
Has the vehicle been customized or altered, or does it have special equipment?
Yes
No
Use:
Service
Retail
Commercial
Other
Secondary Use
Contractor (Other than Dump Truck)
Farmers
Dump and Transit Mix Truck and Trailers
Food Delivery
Logging and Lumbering
Specialized Delivery
Truckers
Waste Disposal
Other
Vehicle 2 Information
(*Required for Medium to Heavy Trucks)
Year / Make / Model / VIN #
Separate cars with commas
Has the vehicle been customized or altered, or does it have special equipment?
Yes
No
Use:
Service
Retail
Commercial
Other
Secondary Use
Contractor (Other than Dump Truck)
Farmers
Dump and Transit Mix Truck and Trailers
Food Delivery
Logging and Lumbering
Specialized Delivery
Truckers
Waste Disposal
Other
Should be Empty: