General Liability Questionnaire

Insurance Agent:

Please select the name of your RealCare agent

1. Named Insured:

DBA

Contact Name:

First NameLast 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

CityState / Province

Postal / Zip Code

Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

2. Type of Ownership:

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?

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?

6. Is the firm engaged in Escrow Services?

7. Is the firm engaged in Mortgage Brokering?

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?

12. Value of Business Personal Property:

Example: desks, computers, chairs, printers, etc.

13. Is your primary location a home office? (office inside a home)

If yes to #13, please provide details:

Please describe your home office situation

14. Do you rent or own your office space?

15. Is your office within city limits?

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:

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?

28. Any prior coverage declined, cancelled or non-renewed in the past three years?

29. Do you currently have a Professional Liability policy?

30. Please list any Additional Insured Needed:

Include additional insureds' name, address, and type (landlord, franchise, leasing agent)

General Liability Questionnaire

Coverage Details

Location