Gessel & Associates Insurance Agency LLC - General Commercial Survey Quote Form

Quote Needed By:*

MonthDayYear
Date
Describe Business Activity:*

Window & Door InstallerSidingExterior Carpentry (Patio Rooms)Interior Carpentry (Kitchen / Bath Remodel)Other (Describe Below)
APPLICANT
Legal Entity Name (Name of Business):*
Doing Business As (DBA):
(*Optional, and typically only used when the legal entity is a sole proprietor. Example- John Smith DBA Smith Construction)
Business Entity Type:*
Describe Business Entity Type
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Person:*
Cell Phone:*
Business Phone:*
Email:*
Federal Employers Tax ID # (FEIN):*
*9 digit number
SS#:*
Website:
Date Business Started:*

MonthDayYear
Date
If new, provide details of Business Experience:
Any bankruptcies, tax or credit liens against the applicant in the past 5 years:*

YesNo
Verbal Disclosure:

Several carriers require the OWNER'S SS# for accurate rating. In connection with this application for insurance, we may review your credit report to obtain and use an insurance loss evaluation score which is based on credit related characteristics, we will use a third party in connection with the development of your insurance loss evaluation score. Entry of the SS# on this survey confirms the owner's acceptance to proceed in cases where the info is needed.
PROPERTY: This section only applies if a physical bricks & mortar location is used for business
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Inside city limits?*

YesNo
Distant (In Feet) from fire hydrant?*
Distant (In Miles) from Fire Department?*
Protect. Class:
For Agency Use Only
Applicant is*

TentantOwner of the building
Triple Net Lease?*

YESNO
If you insure the building, in whose name is the Building deeded?*
Year Built:*
Rennovation dates if over 25 years
Roof:*
Plumbing:*
Electrical:*
Heating:*
Number of stories:*
Construction type:*

FrameJoisted MasonryMasonry Non-CombNon-CombFire Resistive
Total Building Square Feet:*
Your Square Feet:*
Percentage Vacant:*
Sprinklered Percentage:*
List other Building occupants:*
Current Building Coverage:*
Current Deductible:*
Is there a basement?*

YESNO
Business Personal Property coverage amount needed ($5000 Included automatically):*
Tenants’ betterments & improvements needed:*
Alarm Type:*

FireBurglarCentral StationWith Keys
Alarm Company:*
General Liability -
Limit needed:*
Other:
Number of Owners:*
Number of W2 employees (Do Not Include Owners):
Full Time:*
Part Time:*
Annual Payroll (True W-2 Employees only. Do not include Owners):*
Number of 1099 Sub Contractors:*
Amount paid to 1099 Sub Contractors over the next 12 months:*
Gross Annual Receipts:*
IF there are multiple revenue-generating business activities:
Describe The Business Activity & % of Revenue Generated From Each Activity:
Describe The Business Activity & % of Revenue Generated From Each Activity:
Describe The Business Activity & % of Revenue Generated From Each Activity:
Describe The Business Activity & % of Revenue Generated From Each Activity:
Describe The Business Activity & % of Revenue Generated From Each Activity:
Do you currently carry Directors & Officers Liability?*

YESNO
Benefits Questions
Do you offer Employee benefits?*

YESNO
Do you offer 401(K) plans to Employees?*

YESNO
If yes, total 401(K) plan assets*
401(K) plan name:*
LOSS HISTORY STATEMENT:
I, *, have owned and operated * for the past * years. To the best of my knowledge the CLAIMS HISTORY for my company is as follows:
Check if no known losses

IF any known losses, please list below: *

	Name	Description/Type of Loss	Approx. Amount Paid
1
2
3

I attest that, to the best of my knowledge, the information above is correct.

I understand that premiums quoted for my business will be based on the claims history information. I have provided above and that premiums may change based on a “verified loss run” from my current insurance carrier(s).
Applicant Signature

Clear
Date*

MonthDayYear
Should be Empty:

APPLICANT

Verbal Disclosure:

Rennovation dates if over 25 years

General Liability -

LOSS HISTORY STATEMENT: