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TOP WEALTH GROUP Commercial Insurance Questionnaire
TEL: 737-888-0626 EMAIL: AARONLEETOPTAX.COM
General Information
Owner's Name
*
First Name
Last Name
Owner's Date Of Birth (Mandatory)
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Owner's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Name
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Entity
*
Nonprofit
Corporation
Partnership
Individual
LLC
Other
Business established date
*
-
Month
-
Day
Year
Date
FEIN
*
Number of employees
*
Detailed informations about your business
*
Gross Annual Payroll ($)
*
Gross Annual Revenue ($)
*
Insurance coverage requested
*
Business Owner Policy (BOP)
Commercial Auto
General Liability
Workers Compensation
Other
Current Insurance Carrier
Current Policy Expiration 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 (skip to next page if no property coverage is desired)
Building Information
Construction Type
Please Select
fire-resistive
non-combustible
ordinary
heavy timber
wood-framed
other
Year Built
Insured sq feet
Unoccupied sq feet
Year Renovated
Rows
Renovated Year
Roof
Electrical
Plumbing
Heating
Building Security
Rows
Local
Central
None
Fire Alarm
Burglar Alarm
Business Personal Property Value ($)
Building Property Value ($)
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GENERAL LIABILITY
Are you requesting General Liability Coverage
Yes
No
Desired Amount of General Liability Coverage ($)
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Workers' Compensation
Are you requesting Workers’ Compensation Coverage?
Yes
No
Number of Employees
Rows
Full-time
Part-time
Number of Employees
Number of Independent Contractors (ICs)
Rows
Full-time
Part-time
Number of Independent Contractors (ICs)
Are Medical Benefits Offered?
Yes
No
Do you offer Paid Vacation?
Yes
No
Is there a formal Safety Program?
Yes
No
Total Estimated Payroll ($)
Submit
Should be Empty: