Commercial Insurance Questionnaire
General Informations
Company Name:
*
Owner Name:
*
First Name
Last Name
Birthdate:
*
-
Month
-
Day
Year
Date
Social Security #:
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Owner Name 2:
First Name
Last Name
Birthdate:
-
Month
-
Day
Year
Date
Social Security #:
Business Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business established date:
-
Month
-
Day
Year
Date
FEIN:
*
Website:
Legal Entity:
Nonprofit
Corporation
Partnership
Individual
LLC
Other
Number of employees:
Description of Operations:
Gross Annual Payroll ($)
Gross Annual Revenue ($)
Is this business a subsidiary of another entity? If so, what is the parent company's name?
Do you have any subsidiaries? If so, what is the subsidiary's name?
Is there a formal safety program in operation?
Yes
No
Any exposure to flammables, explosives, chemicals?
Yes
No
Any policy or coverage declined, cancelled or non-renewed during the prior three years for any premises or operations?
Yes
No
Any past losses or claims relating to sexual abuse or molestation allegations, discrimination, or negligent hiring?
Yes
No
During the last five years, has any application been indicted for or convicted of any degree of the crime of fraud, bribery, arson, or any other arson-related crime in connection with this or any other property?
Yes
No
Any uncorrected fire and/or safety code violations?
Yes
No
Has the application had a foreclosure filed against them, had a foreclosure, repossession, bankruptcy, or filed for bankruptcy during the last five years?
Yes
No
Has the application had a judgement or lien in the last five years?
Yes
No
Any foreign operations, foreign products distributed in the USA, or US products sold/distributed in foreign countries?
Yes
No
Any other business ventures for which coverage is not requested?
Yes
No
Do you own/lease/operate any drones?
Yes
No
Do you hire others to operate drones?
Yes
No
Insurance coverage requested
Business Owner Policy (BOP)
Commercial Auto
General Liability
Professional Liabilty
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
Own or Lease?
Own
Lease
Building Information
Address if different from business address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Construction Type
Please Select
fire-resistive
non-combustible
ordinary
heavy timber
wood-framed
other
Year Built
Insured sq feet
Unoccupied sq feet
Year Renovated
Rows
Renovated Year
Roof
Electrical
Plumbing
Heating
Building Security
Rows
Local
Central
None
Fire Alarm
Burglar Alarm
Building Property Value ($)
Business Personal Property Value ($)
Annual Gross Revenue ($)
Tools/Equipment Coverage Desired ($)
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GENERAL LIABILITY
Are you requesting General Liability Coverage
Yes
No
Desired Amount of General Liability Coverage ($)
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?
Any subcontract work performed?
If subcontractors are used, do they carry their own general liability at equal limits?
If subcontractors are used, what is the annual cost of their work?
Back
Next
Are you requesting commercial auto coverage?
Yes
No
Driver Information
Rows
Driver 1
Driver 2
Driver 3
Driver 4
Driver Name
Date of Birth
Drivers License #
Vehicles
Rows
Vehicle 1
Vehicle 2
VIN
Year
Make
Model
Value
Custom Equipment (Y/N)
Custom Equipment Value
Vehicles Cont.
Rows
Vehicle 3
Vehicle 4
VIN
Year
Make
Model
Value
Custom Equipment (Y/N)
Custom Equipment Value
Are all vehicles titled to the business?
Yes
No
What radius do your vehicles operate in?
Who are the lienholders for the vehicles, if any?
Are any of the vehicles ever used for personal use?
Yes
No
What coverages would you like quoted on each vehicle?
Submit
Should be Empty: