Commercial Insurance Questionnaire
General Informations
APPLICANT'S NAME
First Name
Last Name
EMAIL
example@example.com
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
MAILING ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PROPERTY ADDRESS / IF THE SAME AS MAILING SKIP TO THE NEXT SECTION
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Business Name
*
Legal Entity
Nonprofit
Corporation
Partnership
Individual
LLC
Other
Business established date
-
Month
-
Day
Year
Date
FEIN
Number of employees
Estimated Projected Gross Annual Payroll ($)
Detailed informations about your business (Give a detailed description of your business)
Estimated Gross Annual Revenue ($)
Insurance coverage requested
Business Owner Policy (BOP)
Commercial Auto
General Liability
Professional Liabilty
Workers' compensation
Other
Current Insurance Carrier
Current Policy Expiration Date
-
Month
-
Day
Year
Date
Current Policy Retroactive 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
List the current carrier
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
Building Property Value ($)
Personal Property Value ($)
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GENERAL LIABILITY
Are you requesting General Liability Coverage?
Yes
No
Desired Amount of General Liability Coverage ($)
Type a question
Rows
Yes
No
Are any autos used exclusively for business use?
Do any employees use a personal auto for business use?
Are any web based services offered?
Are credit card payments accepted?
Is there a program to identify identity theft?
Is there Underground Tank Leakage Exposure?
Is there a Pollution Exposure?
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Professional Liability
Are you requesting Professional Liability Coverage?
Yes
No
Desired Amount of Professional Liability Coverage ($)
Describe Professional Services offered?
Does your firm provide services outside the U.S.?
Yes
No
Percentage of Services for the outside the U.S
Is there a formal Safety Plan?
Yes
No
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
What is the percentage Sub Contractors used if any?
Type a question
Rows
Yes
No
Do you request Certificates of Insurance from ICs and Sub Contractors?
Do you have written agreements on every project?
Do ICs and Sub Contractors have written agreements?
Do you provide Professional Liability to your ICs and Sub Contractors?
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Medical Professional Liability
Are you requesting Medical Professional Liability Coverage if not, skip to next section?
Yes
No
Desired Amount of Professional Liability Coverage ($)
Describe Professional Services offered
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
Type a question
Rows
Yes
No
Do you employ Physicians or Surgeons?
Is there a Medical Director?
Does the Medical Director have their own insurance?
Do you request Certificates of Insurance from ICs and Sub Contractors?
Do you have written agreements on every project?
Do ICs and Sub Contractors have written agreements?
Do you provide Professional Liability to your ICs and Sub Contractors?
Do you bill for Medicare/Medicaid?
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Workers' Compensation
Are you requesting Workers’ Compensation Coverage?
Yes
No
Number of Employees
Rows
Full-time
Part-time
Number of Employees
Number of Independent Contractors (ICs)
Rows
Full-time
Part-time
Number of Independent Contractors (ICs)
Are Medical Benefits Offered?
Yes
No
Do you offer Paid Vacation?
Yes
No
Is there a formal Safety Program?
Yes
No
Total Estimated Payroll ($)
Please verify that you are human
*
Submit
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