Commercial Insurance Questionnaire
For BOP/GL/WC Only
General Information
Company Name
*
Owner's Name
*
First Name
Last Name
Owner's Email
*
example@example.com
Owner's Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Location (Property) Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's Date of Birth
*
/
Month
/
Day
Year
Date
Legal Entity
*
Nonprofit
Corporation
Partnership
Individual
LLC
Other
Business established date
-
Month
-
Day
Year
Date
FEIN
Detailed information about the business
Number of employees
Gross Annual Payroll ($)
*
Gross Annual Revenue ($)
*
Insurance coverage requested
*
Business Owner Policy (BOP)
General Liability Only
Property Only
Commercial Auto
Professional Liability
Workers' compensation
Other
Do they have current insurance now
*
Yes
No
Current Insurance Carrier
*
Current Policy Expiration Date
-
Month
-
Day
Year
Date
Are their any claims/losses in the last 5 years?
*
Yes
No
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
List the current carrier
Building Information
Construction Type
*
Please Selecti
Frame
Brick
fire-resistive
non-combustible
ordinary
wood-framed
Year Built
*
Insured sq feet
*
Unoccupied sq feet
Year Renovated/Updates
*
Rows
Renovated Year
Roof
Electrical
Plumbing
Heating
Building Security
Rows
Local
Central
None
Fire Alarm
Burglar Alarm
Smoke Detectors
Building Property Value ($)
Business Personal Property Value ($)
Annual Gross Revenue ($)
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GENERAL LIABILITY
Are you requesting General Liability Coverage
*
Yes
No
Desired Amount of General Liability Coverage ($)
*
100,000
300,000
500,000
1,000,000
2,000,000
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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Professional Liability
Are you requesting Professional Liability Coverage?
Yes
No
Desired Amount of Professional Liability Coverage ($)
Describe Professional Services offered?
Does your firm provide services outside the U.S.?
Yes
No
Percentage of Services for the outside the U.S
Is there a formal Safety Plan?
Yes
No
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
What is the percentage of your firm’s gross Fees paid to ICs or Sub Contractors last year?
Rows
Yes
No
Do you request Certificates of Insurance from ICs and Sub Contractors?
Do you have written agreements on every project?
Do ICs and Sub Contractors have written agreements?
Do you provide Professional Liability to your ICs and Sub Contractors?
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Medical Professional Liability
Are you requesting Medical Professional Liability Coverage?
Yes
No
Desired Amount of Professional Liability Coverage ($)
Describe Professional Services offered
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
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?
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Workers' Compensation
Are you requesting Workers’ Compensation Coverage?
Yes
No
Is the Owner Inc in Payroll to have coverage for the Owner?
Yes
No
Number of Employees
Rows
Full-time
Part-time
Number of Employees
Total Estimated Payroll Employees Only ($)
Number of Independent Contractors (ICs)
Rows
Full-time
Part-time
Number of Independent Contractors (ICs)
Total Estimated Payroll Sub Contractors/1099 Only ($)
Are Medical Benefits Offered?
Yes
No
Do you offer Paid Vacation?
Yes
No
Is there a formal Safety Program?
Yes
No
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Loss Runs Upload
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Choose a file
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of
Signed No Loss Statement
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Agent Information
Who is submitting this form?
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
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