Business Insurance Information Form

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

First NameLast Name
Business Owner Date of Birth

MonthDayYear
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.
Business Address

Street Address

Street Address Line 2

CityState / 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?
# of stories of the building the business operates out of?
Has the plumbing, electrical, and heating been updated in the past 15 years?
Is your building equipped with fire sprinklers?
Does the building have aluminum wiring?
Is the building undergoing any structural renovation, demolition, or ground-up construction?
Select any protective devices
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

CityState / Province

Postal / Zip Code
Business Structure
EIN #
Do you offer Financial or Insurance Advice? Please check all that apply.
Insurance You are Interested in. Core Property & Casualty Lines
Is this a commercial auto risk?
Commercial Auto Information
Number of vehicles in the fleet
Vehicle types
Primary use of vehicles
Radius of operation
Do any vehicles cross state lines?
Do any vehicles travel into Canada or Mexico?
DOT and Regulatory
DOT Number
MC Number if applicable
Do you have a current FMCSA operating authority?
Are vehicles subject to federal motor carrier safety regulations?
Type of cargo hauled
Driver Information
Driver 1 - Full name

First NameLast Name
Driver 1 - Date of birth

MonthDayYear
Date
Driver 1 - Driver license number
Driver 1 - License state
Driver 1 - License class
Driver 1 - Date of hire

MonthDayYear
Date
Driver 1 - Years of commercial driving experience
Driver 1 - Any violations, accidents, or claims in the past 5 years for this driver?
Driver 1 - Please describe each incident including date, type, and outcome
Driver 2 - Full name

First NameLast Name
Driver 2 - Date of birth

MonthDayYear
Date
Driver 2 - Driver license number
Driver 2 - License state
Driver 2 - License class
Driver 2 - Date of hire

MonthDayYear
Date
Driver 2 - Years of commercial driving experience
Driver 2 - Any violations, accidents, or claims in the past 5 years for this driver?
Driver 2 - Please describe each incident including date, type, and outcome
Driver 3 - Full name

First NameLast Name
Driver 3 - Date of birth

MonthDayYear
Date
Driver 3 - Driver license number
Driver 3 - License state
Driver 3 - License class
Driver 3 - Date of hire

MonthDayYear
Date
Driver 3 - Years of commercial driving experience
Driver 3 - Any violations, accidents, or claims in the past 5 years for this driver?
Driver 3 - Please describe each incident including date, type, and outcome
Driver 4 - Full name

First NameLast Name
Driver 4 - Date of birth

MonthDayYear
Date
Driver 4 - Driver license number
Driver 4 - License state
Driver 4 - License class
Driver 4 - Date of hire

MonthDayYear
Date
Driver 4 - Years of commercial driving experience
Driver 4 - Any violations, accidents, or claims in the past 5 years for this driver?
Driver 4 - Please describe each incident including date, type, and outcome
Driver 5 - Full name

First NameLast Name
Driver 5 - Date of birth

MonthDayYear
Date
Driver 5 - Driver license number
Driver 5 - License state
Driver 5 - License class
Driver 5 - Date of hire

MonthDayYear
Date
Driver 5 - Years of commercial driving experience
Driver 5 - Any violations, accidents, or claims in the past 5 years for this driver?
Driver 5 - Please describe each incident including date, type, and outcome
Loss and Violation History
Has the business had any commercial auto claims in the past 5 years?
If yes, please describe commercial auto claims in the past 5 years
Have any drivers been excluded from prior policies?
If yes, please explain excluded drivers
Have any drivers had a suspended or revoked license in the past 5 years?
If yes, please explain suspended or revoked license incidents
Current Commercial Auto Insurance
Current commercial auto carrier name
Current policy number
Policy expiration date

MonthDayYear
Date
Current liability limits
Current annual premium
Reason for shopping
Commercial Auto Document Uploads
Upload current commercial auto policy declarations page

Cancelof
Upload driver license copies for all listed drivers

Cancelof
Upload MVR reports if available

Cancelof
Upload vehicle schedule or list if available

Cancelof
Estimated Yearly Payroll
Estimated Yearly Revenue
# of FT W-2 Employees not including owners
# 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?
Do you currently have Insurance on your business?
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.
Has the applicant (including any majority owner, partner or member) filed for bankruptcy in the past 5 years?
Has the applicant (including any majority owner, partner or member) filed for bankruptcy in the past 5 years?
Has any policy or coverage been cancelled or non-renewed during the past 3 years?
Please upload a copy of any in force policies or certificates of coverage that you have for your current insurance.

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Have you had any Workman's Compensation or other Liability or Property claims in the past 5 years?
If yes, please provide dates and descriptions of claims.
Do you have employees that leave their normal premises on company business?
Do you have employees that work from home?
Would you also like a quote for Health Insurance or other Employee Benefits?
Is the business a food service operation?
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.
Does the insured have any of the following exposures? Check all that apply.
Are any of the following types of cooking performed?
How often are hoods, grease removal devices, fans, and ducts inspected and cleaned by a properly trained and certified technician?
Are there any remodeling or renovation projects planned for the applicant's premises during the policy term?
Does the establishment provide off-premises catering services?
Does the establishment serve alcohol (beer, liquor, or wine)?
Do you wish to add Hired & Non-Owned Auto Liability coverage?
Does the establishment have stairs used by patrons?
Is the establishment responsible for a parking lot?
Is the premises equipped with a fire sprinkler system?
What type of fire alarm is located at the premises?
What type of burglar alarm is located at the premises?
What type of security cameras are located at the premises?
Does the establishment utilize any of the following third-party delivery services?
What is the construction type of the establishment?
What year was the property built
optional
Is the location of the establishment in any of the following?
Is this a single unit used by the owner or general manager as a residence?
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?
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.
Please enter a Building Limit that represents full replacement cost.
optional
Please select the property All Other Perils deductible.
Please select the property Wind & Hail deductible.
Please select the roof covering type:
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
Is this a commercial auto risk?
Commercial Auto Information
Number of vehicles in fleet
Types of vehicles
What is the primary use of the vehicles?
- Vehicle 1 - Year / Make / Model
- Vehicle 1 - VIN
- Vehicle 1 - Primary use
- Vehicle 2 - Year / Make / Model
- Vehicle 2 - VIN
- Vehicle 2 - Primary use
- Vehicle 3 - Year / Make / Model
- Vehicle 3 - VIN
- Vehicle 3 - Primary use
- Vehicle 4 - Year / Make / Model
- Vehicle 4 - VIN
- Vehicle 4 - Primary use
- Vehicle 5 - Year / Make / Model
- Vehicle 5 - VIN
- Vehicle 5 - Primary use
- Vehicle 6 - Year / Make / Model
- Vehicle 6 - VIN
- Vehicle 6 - Primary use
- Vehicle 7 - Year / Make / Model
- Vehicle 7 - VIN
- Vehicle 7 - Primary use
- Vehicle 8 - Year / Make / Model
- Vehicle 8 - VIN
- Vehicle 8 - Primary use
- Vehicle 9 - Year / Make / Model
- Vehicle 9 - VIN
- Vehicle 9 - Primary use
- Vehicle 10 - Year / Make / Model
- Vehicle 10 - VIN
- Vehicle 10 - Primary use
- Should be Empty:

Business Insurance Information Form

Commercial Auto Information

DOT and Regulatory

Driver Information

Loss and Violation History

Current Commercial Auto Insurance

Commercial Auto Document Uploads

Restaurant Specific Questions (Skip this section if not a food service operation)

Commercial Auto Information