Business Insurance Information Form
Please fill the form as completely as possible for better assistance. The email box that this form is submitted to is monitored continuously and someone will be in touch with you very shortly once the form is submitted. Many of the fields aren't marked as required, however the more information you provide, the better able we are to assist you. All Data is encrypted. Landsman Insurance Services, LLC. NPN: 21500715 - 1-833-208-0034
Business Owner Name
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First Name
Last Name
Business Owner Date of Birth
*
-
Month
-
Day
Year
Date
Month and Year Business Started
*
E-Mail
*
Email
Phone Number
*
Format: (000) 000-0000.
Company Name
*
Company Name
Company Website
Company Name
Tell us about your business. What products or services do you offer, how many employees you have, and whether you operate from a physical location, online, or both? This will help us recommend the right insurance coverages for your needs.
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Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many years experience does the owner have in this industry?
*
Are there multiple units (residential or commercial) in your building?
*
Yes
No
# of stories of the building the business operates out of?
*
Has the plumbing, electrical, and heating been updated in the past 15 years?
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Yes
No
Is your building equipped with fire sprinklers?
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Yes
No
Does the building have aluminum wiring?
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Yes
No
I don't know
Is the building undergoing any structural renovation, demolition, or ground-up construction?
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Yes
No
I don't know
Select any protective devices
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Local Burglar Alarm
Central Burglar Alarm
Local fire Alarm
Central Fire Alarm
None
What year was this building built? (If you don't know please say Unknown)
*
How many square feet does the business occupy?
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Structure
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Sole Proprieter
Partnership
LLC
Corporation C-Corp
Corporation S-Corp
Nonprofit Corporation
EIN #
*
Do you offer Financial or Insurance Advice? Please check all that apply.
Yes, Financial
Yes, Insurance
No
Insurance You are Interested in. Core Property & Casualty Lines
Business Owners Policy (BOP) – Combines property and general liability; ideal for small businesses.
Commercial Property Insurance — Covers buildings, equipment, inventory, etc.
General Liability Insurance — Protects against third-party bodily injury and property damage.
Commercial Auto Insurance — Covers vehicles used for business purposes.
Workers' Compensation — Required in most states; covers employee injuries.
Commercial Umbrella Insurance — Provides excess liability above primary policies.
Unsure or Not Needed
Estimated Yearly Payroll
*
Estimated Yearly Revenue
*
# of FT W-2 Employees not including owners
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# of PT W-2 Employees not including owners
*
# of 1099 workers
*
Are all 1099 workers required to add your business as a named insured on their policy?
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Yes
No
N/A
Do you currently have Insurance on your business?
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Yes
No
If yes to the above question, please provide carrier(s) name(s) and type of insurance with each.
List Additional Owners of the Business and the % Ownership of each
Does your business conduct any if the following? Check all that apply.
*
Third-party background checksfor all new employees, volunteersand subcontractors
Annual or more frequent third-party background checks forexisting employees, volunteersand subcontractors
Written hiring and employmentpolicy mandating zero tolerancetowards all forms of sexualabuse, molestation ormisconduct
Have a policy against hiring employees, volunteers or subcontractors with allegations, claims, charges or possessing a record of sexual abuse, molestation or misconduct
None of the above
Has the applicant (including any majority owner, partner or member) filed for bankruptcy in the past 5 years?
*
Yes
No
Has the applicant (including any majority owner, partner or member) filed for bankruptcy in the past 5 years?
*
Yes
No
Has any policy or coverage been cancelled or non-renewed during the past 3 years?
*
Yes
No
Please upload a copy of any in force policies or certificates of coverage that you have for your current insurance.
Browse Files
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of
Have you had any Workman's Compensation or other Liability or Property claims in the past 5 years?
*
Yes
No
If yes, please provide dates and descriptions of claims.
Do you have employees that leave their normal premises on company business?
Yes
No
Do you have employees that work from home?
Yes
No
Would you also like a quote for Health Insurance or other Employee Benefits?
Yes
No
Is the business a food service operation?
*
Yes
No
Restaurant Specific Questions (Skip this section if not a food service operation)
Does the establishment offer any of the below? Please check all that apply.
Happy hour between 8pm-close
Serves liquor and operates between the hours of midnight and 5am
Alcohol service over two hours after food service ends
Alcoholic drink specials under $4 (other than standard cans or bottles of beer)
Complimentary alcoholic drinks, buy-one-get one offers, or all-you-can-drink specials
Hazardous amusement devices or activities (e.g. mechanical bulls, axe throwing, darts...)
Live concerts with 3 or more performers with a dance floor or dance area
Door bouncers (beyond a single ID checker)
Sports activities (e.g. volleyball, boxing, bowling...)
Hosting special events beyond standard in-house promotions (e.g. street fair, block party)
Dance floor
ATM
Hookah
Flaming food or beverages
A playground on the premises?
Have more than 6 deep fat fryer units
None of the above
Does the insured have any of the following exposures? Check all that apply.
Own and operate a food truck or food cart
Operate a temporary food stand at events
Sublease the insured location as a ghost kitchen at any time
Operate a virtual brand out of the insured location
None of the above
Are any of the following types of cooking performed?
Solid Fuel Indoors
Wok
Charbroiling
None of the above
How often are hoods, grease removal devices, fans, and ducts inspected and cleaned by a properly trained and certified technician?
Never
Annually
Semi-Annually
Quarterly
Monthly
Not Applicable
Are there any remodeling or renovation projects planned for the applicant's premises during the policy term?
Yes
No
Does the establishment provide off-premises catering services?
Yes
No
Does the establishment serve alcohol (beer, liquor, or wine)?
Yes
No
Do you wish to add Hired & Non-Owned Auto Liability coverage?
Yes
No
Does the establishment have stairs used by patrons?
Yes
No
Is the establishment responsible for a parking lot?
Yes
No
Is the premises equipped with a fire sprinkler system?
Yes
No
What type of fire alarm is located at the premises?
UL Certified Central Station
Central Station
Local
None
What type of burglar alarm is located at the premises?
Central Station
Local
None
What type of security cameras are located at the premises?
Centrally Monitored
Recording Only
None
Does the establishment utilize any of the following third-party delivery services?
Uber Eats, Doordash, etc.
Robotic delivery
None
What is the construction type of the establishment?
Frame
Joisted Masonry
Non Combustible
Masonry non-combustible
Modified fire resistive
Fire Resistive
What year was the property built
optional
Is the location of the establishment in any of the following?
Attached to habitational structure (apartments, condos)
Stand-alone building
Strip shopping center
Enclosed mall
None of the above
Is this a single unit used by the owner or general manager as a residence?
Yes
No
What is the total area (square feet) of the building or unit occupied by the insured?
optional
What is the establishment's maximum occupancy?
optional
What do you estimate as the value of all business property (kitchen equipment, tables, glassware, POS System, etc.) in the event of a total loss?
optional
What year was the roof last replaced
optional
Do you wish to add Building Coverage?
Yes
No
Do you wish to add Ordinance or Law Coverage (Coverage A Included) ($10,000 Combined B and C Limit - Premier)? Ordinance or Law coverage helps pay for extra costs you might face if your home is damaged and has to be rebuilt or repaired in compliance with current building codes. Coverage A included – the main dwelling coverage is automatically extended. Coverage B (Other Structures) and C (Personal Property) – the $10,000 “combined limit” is what applies to these areas under the Premier option.
Yes
No
Please enter a Building Limit that represents full replacement cost.
optional
Please select the property All Other Perils deductible.
$500
$1,000
$2,500
$5,000
$10,000
$25,000
Please select the property Wind & Hail deductible.
1%
2%
5%
Remove Coverage
Please select the roof covering type:
Shingle
Membrane
Metal
Tar and Gravel
Tile
Wood Shake
What year was the electrical wiring last updated?
optional
What year was the plumbing last updated?
optional
What are the average hours this establishment is open to the public each day? (please round down to nearest whole number)
optional
What year did the establishment open?
optional
# of Full-Time Employees
optional
# of Part-Time Employees
optional
Submit Form
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