Commercial Insurance Questionnaire

Commercial Insurance Questionnaire
Business Information
Full Legal Business Name*
DBA (if different)
Business Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Website
Primary Contact Name*

First NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Sole ProprietorLLCCorporationPartnershipOther
Year Business Established
FEIN / Tax ID*
Number of Full-Time Employees*
Number of Part-Time / Seasonal Employees
Brief Business Description
Current Insurance
Current Insurance Carrier(s)
Policy Expiration Date(s)
Current Annual Premium Total
Lines of Coverage Currently Carried
PriceServiceCoverage GapsNon-RenewedNew BusinessOther
YesNo
If yes, briefly describe the claims
YesNo
If yes, number of claims and approximate total paid
Commercial Auto
YesNo
Number of vehicles to be covered*
Vehicle Primary Use
Vehicle Info (year make & Model) or VIN
Please add info for all vehicles here
Vehicles Annual Radius
YesNo
Garaging ZIP if different from business address
Drivers
Driver 1 Full Name*

First NameMiddle NameLast Name
Driver 1 Date of Birth*

MonthDayYear
Date
Driver 1 License Number*
Driver 1 License State*
Driver 1 Years Licensed*
Driver 1 Violations or Accidents in Past 5 Years
Driver 2 Full Name

First NameMiddle NameLast Name
Driver 2 Date of Birth

MonthDayYear
Date
Driver 2 License Number
Driver 2 License State
Driver 2 Years Licensed
Driver 2 Violations or Accidents in Past 5 Years
Driver 3 Full Name

First NameMiddle NameLast Name
Driver 3 Date of Birth

MonthDayYear
Date
Driver 3 License Number
Driver 3 License State
Driver 3 Years Licensed
Driver 3 Violations or Accidents in Past 5 Years
Driver 4 Full Name

First NameMiddle NameLast Name
Driver 4 Date of Birth

MonthDayYear
Date
Driver 4 License Number
Driver 4 License State
Driver 4 Years Licensed
Driver 4 Violations or Accidents in Past 5 Years
Driver 5 Full Name

First NameMiddle NameLast Name
Driver 5 Date of Birth

MonthDayYear
Date
Driver 5 License Number
Driver 5 License State
Driver 5 Years Licensed
Driver 5 Violations or Accidents in Past 5 Years
General Liability
YesNo
Gross Annual Revenue
GL Occurrence Limit Needed
Aggregate Limit Needed
Detailed description of all operations and services
Where do operations take place - fixed location, mobile, client sites, events, etc
YesNo
YesNo
If yes to subcontractors, what is their payroll?
YesNo
YesNo
If yes, describe products
YesNo
YesNo
Additional Insured required?
Other Coverages
Umbrella/Excess LiabilityInland Marine/EquipmentWorkers CompensationCyber LiabilityCommercial PropertyEPLINone
Umbrella limit needed
Value of equipment or tools to insure
Workers compensation total payroll
States where employees work
Commercial property address if different

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Building value replacement cost
Business personal property value
Additional Notes
Anything else we should know about your business or operations?
Best time to reach you
GoogleReferralSocial MediaOther
Should be Empty:

Business Information

Current Insurance

Commercial Auto

Drivers

General Liability

Other Coverages

Additional Notes