Commercial Insurance Questionnaire
To apply for an insurance quote please complete all questions. An agent will get back to you within 24 hours.
General Information
Applicant Name
*
First Name
Last Name
SSN
*
Email
*
example@example.com
Fair Credit Reporting Act
*
I acknowledge my Credit Score will be used in the underwriting process
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Driver's License Number
*
Copy of Driver's License
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More than one Owner?
*
Yes
No
Owner 2
*
First Name
Last Name
SSN
*
Driver's License Number
*
Email
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Copy of Driver's License
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Business 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
Number of employees
*
FEIN
*
SIC Code
*
Detailed information about your business
*
Gross Annual Revenue ($)
*
Gross Annual Payroll ($)
*
Company Filing Receipt
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Most Recent 941
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Insurance coverage requested
*
Business Owner Policy (BOP)
Commercial Auto
General Liability
Professional Liability
Workers' compensation
Medical Professional Liability
Commercial Umbrella
Commercial Property
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
Current Policy
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Loss Run Report (3-5 year Report)
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Provided by your current insurance carrier
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PROPERTY DETAILS
Are you requesting Property Coverage
*
Yes
No
Building Information
Construction Type
Please Select
fire-resistive
non-combustible
ordinary
heavy timber
wood-framed
other
Year Built
Insured sq feet
Public Use sq feet
Unoccupied sq feet
Fire Extinguisher
Yes
No
Year Renovated
*
Rows
Renovated Year
Roof
Electrical
Plumbing
Heating
Building Security
*
Rows
Local
Central
None
Fire Alarm
Burglar Alarm
Building Property Value ($)
Annual Gross Revenue ($)
Personal Property Value ($)
GENERAL LIABILITY
Are you requesting General Liability Coverage
Yes
No
Desired Amount of General Liability Coverage ($)
Additional Information
*
Rows
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?
Professional Liability
Are you requesting Professional Liability Coverage?
Yes
No
Desired Amount of Professional Liability Coverage ($)
Describe Professional Services offered?
Does your firm provide services outside the U.S.?
Yes
No
Percentage of Services for the outside the U.S
Is there a formal Safety Plan?
Yes
No
Does your firm use Independent Contractors (ICs) or Sub Contractors?
*
Yes
No
What is the percentage of your firm’s gross Fees paid to ICs or Sub Contractors last year?
Additional Information
*
Rows
Yes
No
Do you request Certificates of Insurance from ICs and Sub Contractors?
Do you have written agreements on every project?
Do ICs and Sub Contractors have written agreements?
Do you provide Professional Liability to your ICs and Sub Contractors?
Medical Professional Liability
Are you requesting Medical Professional Liability Coverage?
Yes
No
Desired Amount of Professional Liability Coverage ($)
Describe Professional Services offered
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
Additional Information
*
Rows
Yes
No
Do you employ Physicians or Surgeons?
Is there a Medical Director?
Does the Medical Director have their own insurance?
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?
Do you bill for Medicare/Medicaid?
Workers' Compensation
Are you requesting Workers’ Compensation Coverage?
Yes
No
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)
Are Medical Benefits Offered?
Yes
No
Is there a formal Safety Program?
Yes
No
Total Estimated Payroll ($)
Commercial Auto
Vehicle List
*
Rows
Year
VIN
Make
Model
Lien-holder Info
Work Radius
Annual Mileage
Current Mileage
Vehicle 1
Leased
Financed
Owned
<50 Miles
50-100 Miles
>100 Miles
Vehicle 2
Leased
Financed
Owned
<50 Miles
50-100 Miles
>100 Miles
Vehicle 3
Leased
Financed
Owned
<50 Miles
50-100 Miles
>100 Miles
Vehicle 4
Leased
Financed
Owned
<50 Miles
50-100 Miles
>100 Miles
Safety Features
*
Rows
Passive Alarm
Active Alarm
GPS Tracking
VIN Etch
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Drivers
*
Rows
Sex
DOB
License #
SSN
Cell Phone
DDC Course
Driving Experience
Driver 1
Male
Female
Yes
No
Driver 2
Male
Female
Yes
No
Driver 3
Male
Female
Yes
No
Driver 4
Male
Female
Yes
No
Current Auto Policy
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*
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