Commercial Insurance Questionnaire
Please complete the information below. IMPORTANT: This form is not an insurance policy - it is general information necessary to prepare a quotation. Note that many carriers require a complete signed carrier application specific to their product offerings.
I. General Information
Applicant
*
First Name
Last Name
Business Name
*
Doing Business As
If applicable
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
Web Address
*
www.example.com
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Principal Contact Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Legal Entity
*
Corporation
Partnership
Not for Profit
LLC
Individual
Other
Date Business Established
*
 -
Month
 -
Day
Year
FEIN
*
Years in Operation
*
Years of Owner Experience in Industry
*
Description of Operations
*
Min 10 words
Number of Full Time Employees
*
Number of Part Time Employees
*
Gross Annual Payroll
*
Gross Annual Revenue
*
Insurance Coverage Requested
*
Business Owners Policy (BOP)
Commercial Auto
General Liability
Professional Liability
Workers' Comp
Other
Current Insurance Carrier
*
If no insurance, enter NONE
Current Policy Expiration Date
*
 -
Month
 -
Day
Year
Date
Current Policy Retroactive Date
*
 -
Month
 -
Day
Year
Date
Curent Limits
*
Desired Effective Date of New Policy
*
 -
Month
 -
Day
Year
Date
Desired Limits
*
Desired Deductable
*
II. Property Details
Are you requesting Property Coverage?
*
Yes
No
If no, list the current carrier
*
If no current insurance, enter NONE
Is there Boiler Machinery Coverage Exposure?
*
Yes
No
Is there Earthquake Sprinkler Leakage Exposure?
*
Yes
No
Is there Underground Tank Leakage Exposure?
*
Yes
No
Do employees handle cash?
*
Yes
No
Building Ownership
*
Owned
Triple Net Lease
Lease
IV. General Liability
Location 1
Location Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insured Square Footage
*
Occupied Square Footage
*
Unccupied Square Footage
*
Total Square Footage
*
Describe other occupancies
*
Construction Type
*
Number of Stories
*
Percent Sprinklered
*
Building within City Limits?
*
Yes
No
Year Built
*
Year Rennovated
*
Year Renovated - Mandatory if building is greater than 10 years old
Rows
Roof
Electrical
Plumbing
Heating/AC
Year
Building Security
Fire Alarm
*
None
Local
Central
Burglar Alarm
*
None
Local
Central
Smoke Detectors
*
None
Battery
Hardwired
Property Values
Building
*
Personal Property
*
Stock
*
Business Income
Annual Gross Revenue
*
Total Square Footage
*
Location 2
Location Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insured Square Footage
Occupied Square Footage
Unccupied Square Footage
Total Square Footage
Describe other occupancies
Construction Type
Number of Stories
Percent Sprinklered
Building within City Limits?
Yes
No
Year Built
Year Rennovated
Year Renovated - Mandatory if building is greater than 10 years old
Rows
Roof
Electrical
Plumbing
Heating/AC
Year
Building Security
Fire Alarm
None
Local
Central
Burglar Alarm
None
Local
Central
Smoke Detectors
None
Battery
Hardwired
Property Values
Building
Personal Property
Stock
Business Income
Annual Gross Revenue
Total Square Footage
Location 3
Location Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insured Square Footage
Occupied Square Footage
Unccupied Square Footage
Total Square Footage
Describe other occupancies
Construction Type
Number of Stories
Percent Sprinklered
Building within City Limits?
Yes
No
Year Built
Year Rennovated
Year Renovated - Mandatory if building is greater than 10 years old
Rows
Roof
Electrical
Plumbing
Heating/AC
Year
Building Security
Fire Alarm
None
Local
Central
Burglar Alarm
None
Local
Central
Smoke Detectors
None
Battery
Hardwired
Property Values
Building
Personal Property
Stock
Business Income
Annual Gross Revenue
Total Square Footage
IV. General Liability
Are you requesting General Liability Coverage?
*
Yes
No
If no, list the current carrier
If no current insurance, enter NONE
Desired Amount of General Liability Coverage
*
Are Professional Services offered?
*
Yes
No
If yes, please describe
Min 10 words
Are any autos used exclusively for business use?
*
Yes
No
Do any employees use a personal auto for business use?
*
Yes
No
Are any web based services offered?
*
Yes
No
Are credit card payments accepted?
*
Yes
No
Is there a program to identify identity theft?
*
Yes
No
Is there Underground Tank Leakage Exposure?
*
Yes
No
Is there a Pollution Exposure?
*
Yes
No
V. Additional Coverage Interests
Check all that apply:
*
Commercial Umbrella
Buy/Sell Agreement
Crime/Employee Dishonesty
Cyber Liability
Directors and Officer Liability
Employee Practices Liability
Bonds
Medicare/Medicade Billing E&O
Regulatory Shut Down
Other
Please list any entities the Named Insured desires to have listed as an additional insured/loss payee on the policy and the nature of their interest to the policyholder:
Person 1
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Interest
Person 2
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Interest
Submit
Should be Empty: