Schomburg Insurance Commercial Intake Questionaire

1
How did you hear about us?* This field is required.
2
What type of coverage does your business need?* This field is required.Select All That Apply
General Liability
Property/Building
Business Personal Property - On Premises
Business Personal Property - Off Premises
Commercial Auto (will need current Declarations Pages and Loss Runs of current policy)
Workers' Comp
Professional Liability
Other
3
Describe your Other Coverage needs* This field is required.
4
Primary Contact* This field is required.
First Name
Last Name
Please enter your phone
Please enter your email
Please Select
Phone
Email
Text
Preferred Contact Method (select all that apply)
Best Time to Contact
Please Select
Please Select
Yes
No
Is the Primary Contact the Owner?
5
Additional Owner Information* This field is required.
Date of Birth
# of Years of Experience in this Field
6
What is your role in this business?* This field is required.
7
Owner's Information* This field is required.
First Name
Last Name
Date of Birth
# of Years of Experience in this Field
8
Business Name
Full Legal Business Name
DBA (if applicable)
9
Business Information
Please Select
Please Select
Association
Corporation
Individual
Limited Liability Company
Partnership
Trust
Entity Type
Federal Employee ID
Annual Revenue
Annual Payroll
Sub Costs
Year Business Started
Website URL
10
Description of Operations and Summary of Scope of work* This field is required.
11
Physical Address* This field is required.
Street Address
Street Address Line 2
City
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
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Is your Mailing Address different from your Physical Address?* This field is required.
YESNO
13
Mailing Address* This field is required.
Street Address
Street Address Line 2
City
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
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
Do you have employees?* This field is required.
YESNO
15
Employee Information
# of Full Time Employees
Duties/Class
Annual Salary
# of Part Time Employees
Duties/Class
Annual Salary
16
What type of office do you have?* This field is required.
Home Office
Commercial Office - Leased
Commercial Office - Owned
17
Home Office Information
Year Built
Age of Roof
18
Commercial Office - Leased* This field is required.
Year Built
Square Feet
Please Select
Please Select
Frame
Jointed Masonry
Steel
Non-Combustible
Type of Construction
Please Select
Please Select
Yes
No
Sprinklered?
Year Roof was last Updated
Year Plumbing was last Updated
Year Heating was last Updated
Year Electrical was last Updated
19
Commercial Office - Owned* This field is required.
Year Built
Square Feet
Please Select
Please Select
Frame
Jointed Masonry
Steel
Non-Combustible
Type of Construction
Please Select
Please Select
Yes
No
Sprinklered?
Year Roof was last Updated
Year Plumbing was last Updated
Year Heating was last Updated
Year Electrical was last Updated
20
Building Replacement Value
21
Is there a Security System in place?* This field is required.
YESNO
22
Please describe your Security System* This field is required.
23
Description and Value of Business Personal Property* This field is required.
Huge
Large
Normal
Small
Ok
Ok
24
How many vehicles are titled to the business?* This field is required.
25
Vehicle 1
Year
Make
Model
Cost New
VIN
26
Vehicle 2
Year
Make
Model
Cost New
VIN
27
Vehicle 3
Year
Make
Model
Cost New
VIN
28
Vehicle 4
Year
Make
Model
Cost New
VIN
29
Vehicle 5
Year
Make
Model
Cost New
VIN
30
Vehicle 6
Year
Make
Model
Cost New
VIN
31
All Additional Vehicles Titled to the BusinessInclude Year, Make, Model and, if known, VIN & Cost New for each vehicle
Huge
Large
Normal
Small
Ok
Ok
32
How many people drive the business vehicles? (unlisted drivers will not be covered in the event of a claim)* This field is required.We will need all Driver & License info. Upload a copy of each valid driver's license at the end of this form..
33
List All Drivers of Business VehiclesInclude First & Last Name, Date of Birth, Driver's License Number & # of Accidents in the last 3 years. Upload a copy of each valid driver's license at the end of this form.
Huge
Large
Normal
Small
Ok
Ok
34
Do you have current insurance?* This field is required.
YESNO
35
Current Policy Information
Current Provider
Policy Expiration Date
Please Select
General Liability
Property/Building
Business Personal Property - On Premises
Business Personal Property - Off Premises
Commercial Auto
Workers' Comp
Professional Liability
Other (Please Explain)
Types of Coverage (select all that apply)
Explain Other Coverage (if selected)
Please Select
Please Select
Yes
No
Any claims in the last 5 years?
Please Select
Please Select
Yes
No
Do you have any additional policies?
36
Information about Additional PoliciesInclude Current Provider, Expiration Date & Type of Coverage for each policy
Huge
Large
Normal
Small
Ok
Ok
37
Have any claims been filed within the last 5 years on any of the additional policies listed?* This field is required.
YESNO
38
Explain All Claims Filed within the Last 5 Years* This field is required.
Huge
Large
Normal
Small
Ok
Ok
39
Please attach all Declarations Pages and Loss Runs for Current PoliciesIf Available
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
40
Attach Driver's Licenses for all Drivers
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
41
Explain any Special Requests or Concerns
Huge
Large
Normal
Small
Ok
Ok
42
By clicking Submit below, I am giving permission to Schomburg Insurance to contact me by phone, text or email regarding my insurance inquiry.
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