Business Insurance Questionnaire
Business Name
Years in business?
Entity Type
Please Select
Corporation
LLC
Partnership
DBA
Sole Proprietor
Individual
Other
Number of Owners/Corporate Officers/LLC Members?
Please Select
0
1
2
3
4
5
Other
Explain your business. What do you sell? What do you make or manufacture? What is your trade? Don't hold back, tell us everything about your business. If you have a website, include your website link here too.
Email
example@example.com
EIN Number
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Method of Contact
Please Select
Call
Text
Email
Ok to Text
Yes
No
Your Name
First Name
Last Name
Title
Please Select
Owner
Corporate Officer
LLC Member
Sole Proprietor
Individual
Other
Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Current Insurance Information
Is your business currently insured?
Yes
No
New Business (first time insuring)
Is this business run out of your home?
Please Select
YES
NO
Current Insurance Carrier Name
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date your current insurance expires?
Here's where we start saving you $$$
How much do you pay now?
Premium Mode
Please Select
monthly
quarterly (4x's/yr)
semi-ann. (2x's/yr)
annually (1x/yr)
How often do you pay your premium?
How many liability claims in the last 5 years?
Please Select
0 - You're on your way to savings!!$$!!
1
2
3+
How many property claims in the last 5 years?
Please Select
0 - Oh ya! you're gonna save some $$
1
2
3+
Commercial General Liability Limit
Please Select
300,000/600,000
500,000/1,000,000
1,000,000/2,000,000
2,000,000/4,000,000
Other
Construction Type
Please Select
Masonry w/steel
Masonry w/wood
Wood
Vinyl
Aluminum
Stucco
Other
Coverage Selection
Business Personal Property
How much coverage do you need for personal property? Includes coverage for all inventory, equipment, computers, POS, racks, etc...
Choose your deductible
Please Select
$500
$1,000
$2,500
$5,000
$10,000
Deductible
Your space square footage
Total Square footage of your space
Protective Devices
Please Select
Central Burglar & Fire Alarm.
Central Burglar only
Central Fire only
Cameras
None
Approximate Annual Sales
Annual Sales
Approximate Annual Payroll
Annual Payroll
Full-Time Employees
(40 hrs./wk. or more) DO NOT include owners as employees.
Part-Time Employees
(Under 40 hrs./wk.) DO NOT include owners as employees.
You can upload your current policy declarations here!
Browse Files
Drag and drop files here
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If you own the building where your business is located, please continue to the next section. If you DO NOT own the building, please click Submit now.
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Building Information
Total Building Square Footage
Year Built
Year Roof Last Updated?
Roof Material Type?
Please Select
Asphalt Shingle
Architectural Shingle
Rubber
Tile/Slate
Built up/tar
Other
Year HVAC last updated?
Is your HVAC on the ground or rooftop?
Please Select
Ground
Rooftop
What is your primary heat source?
Please Select
Natural Gas
Electric
Hot Water
Boiler
Propane
Other
Type of WIRING
Please Select
Breaker Box
Fuses
I don't know
Year WIRING last updated?
Year PLUMBING last updated?
Number of Stories
If there are other businesses other than your own business in your building, please provide the type of business and the square footage they occupy:
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Should be Empty: