Commercial Insurance Questionnaire
General Informations
Applicant Name
*
First Name
Last Name
Email
example@example.com
Contact Number
*
Please enter a valid phone number.
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
FEIN
*
Number of employees
Detailed informations about your business
Gross Annual Payroll ($)
Gross Annual Revenue ($)
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
Who is your current insurance carrier?
Building Information
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 ($)
Building Property Value ($)
Building Property Value ($)
Personal Property Value ($)
Annual Gross Revenue ($)
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GENERAL LIABILITY
Are you requesting General Liability Coverage
Yes
No
Desired Amount of General Liability Coverage ($)
Type a question
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?
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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 any of the vehicles ever used for personal use?
Yes
No
What coverages would you like quoted on each vehicle?
Submit
Should be Empty: