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
Renovated Year
Roof
Electrical
Plumbing
Heating
Building Security
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
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
Driver 1
Driver 2
Driver 3
Driver 4
Driver Name
Date of Birth
Drivers License #
Vehicles
Vehicle 1
Vehicle 2
VIN
Year
Make
Model
Value
Custom Equipment (Y/N)
Custom Equipment Value
Vehicles Cont.
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: