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
Entity Type

Other
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
Reason for Shopping

Other
Any open or pending claims?
If yes, briefly describe the claims
Claims in past 5 years?
If yes, number of claims and approximate total paid
Commercial Auto
Do you need Commercial Auto coverage?
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
Do employees drive company vehicles?
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
Do you need General Liability coverage?
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
Do you have written contracts with clients?
Do you use subcontractors?
If yes to subcontractors, what is their payroll?
Do you require COIs from subcontractors?
Do you sell products to customers?
If yes, describe products
Is alcohol served or sold?
Do you work on others property?
Additional Insured required?
Other Coverages
Other coverages needed
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
How did you hear about us?

Other
Should be Empty:

Business Information

Current Insurance

Commercial Auto

Drivers

General Liability

Other Coverages

Additional Notes