General Liability Questionnaire
General Liability Insurance
Insurance Agent:
*
Please Select
Susie Pusich
Kristin Fall
Rebecca Squires
Melissa Isaiyas
I don't know
I don't have an agent
Please select the name of your RealCare agent
1. Named Insured:
*
DBA
*
Contact Name:
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2. Type of Ownership:
*
Please Select
Corporation/LLC
Individual/Sole Proprietor
Partnership
Independent Contractor
Other
3. Date Business Started (if less than 3 years, provide years of management experience):
*
If business started less than 3 years ago, provide the years of management experience
4. Description of Operations:
*
Please describe your business operations
5. Is the firm engaged in Property Management?
*
Yes
No
If yes to #5, what percentage of revenue is attributable to Property Management Services
% of business derived from property management
If yes to #5, do you obtain certificates of general liability insurance naming you as additional insured on any contractor or service provider’s policy?
Yes
No
6. Is the firm engaged in Escrow Services?
*
Yes
No
7. Is the firm engaged in Mortgage Brokering?
*
Yes
No
Coverage Details
8. How many people are in your firm?
*
Provide total number of people including officers, agents, employees, and 1099 contractors
9. How many officers/owners/partners are there in the firm?
*
Total # of owners, officers, and partners in the firm
10. Total Annual Revenue
*
Total gross revenue
11. Do you sell tract homes?
*
Yes
No
12. Value of Business Personal Property:
*
Example: desks, computers, chairs, printers, etc.
Location
13. Is your primary location a home office? (office inside a home)
*
Yes
No
If yes to #13, please provide details:
Please describe your home office situation
14. Do you rent or own your office space?
*
Rent
Own
15. Is your office within city limits?
*
Yes
No
16. Square Footage Occupied:
*
Total square footage of your office building
17. Square Footage of Building:
*
Total square footage of your entire office building
18. Year Built:
*
Year your office building was built
19. Construction Type (relating to fire resistance):
*
Example: wood-frame, heavy timber, non-combustible, fire-resistive.
20. Roofing Type:
*
Example: metal, asphalt, wood shingle, slate, etc.
21. Number of Stories/Floors:
*
# of floors in office building
22. Percent Sprinklered (indoors):
*
What percentage of square footage has indoor fire sprinklers?
23. Year of Last Building Updates (only needed for buildings over 50 years old):
Rows
Electric
Plumbing
Roof
Heating
Year
24. Alarm System Type:
*
Central
Local
None
25. Distance to Fire Hydrant:
*
Approximate distance to the nearest fire hydrant
26. Distance to Fire Station:
*
Approximate distance to the nearest fire station
27. Do you have a current BOP policy?
*
Yes
No
28. Any prior coverage declined, cancelled or non-renewed in the past three years?
*
Yes
No
29. Do you currently have a Professional Liability policy?
*
Yes
No
30. Please list any Additional Insured Needed:
Include additional insureds' name, address, and type (landlord, franchise, leasing agent)
Submit
Should be Empty: