Commercial Insurance Questionnaire
General Informations
Applicant Name
*
First Name
Last Name
Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What is your company's website?
Business established date
*
-
Month
-
Day
Year
Date
Legal Entity
*
Nonprofit
Corporation
Partnership
Individual
LLC
Other
FEIN or Social Security # if (Sole Proprietor or Partnership)
*
SIC Code
A SIC code is a four or five digit number used to classify a company's main business activity. Please skip if you are unsure.
SIC CODE LOOK UP
Number of employees
*
Anticipated W2 payroll for the 2026
*
This is the amount of W2 wages your company expects to pay in current calendar year.
Number of 1099 contractors
This is the amount of 1099 Contractor pay your company expects to pay in current calendar year.
Anticipated 1099 payroll for the 2026
This is the amount of 1099 (Contractor) wages your company expects to pay in current calendar year.
Detailed informations about your business
What exactly does your company do? Does your company work on residential, commercial or both?
Gross Annual Payroll ($)
*
How much did your company pay for W2 employees and contractors, combined last year?
Gross Annual Revenue ($)
*
How much did your company earn last year?
Insurance coverage requested
*
Business Owner Policy (BOP)
Commercial Auto
General Liability
Professional Liabilty
Workers' compensation
Group Health Insurance
Group Life Insurance
Retirement (401K)
Inland Marine (Business Equipment)
Other
Business Owners Policy (BOP) Insurance Carrier
*
Type (NA) if you have no current policy.
Current Policy Expiration Date
-
Month
-
Day
Year
Date
Commercial Auto Insurance Carrier
*
Type (NA) if you have no current policy.
Current Policy Expiration Date
-
Month
-
Day
Year
Date
General Liability Insurance Carrier
*
Type (NA) if you have no current policy.
Current Policy Expiration Date
-
Month
-
Day
Year
Date
Professional Liablity Insurance Carrier
*
Type (NA) if you have no current policy.
Current Policy Expiration Date
-
Month
-
Day
Year
Date
Worker's Compensation Insurance Carrier
*
Type (NA) if you have no current policy.
Current Policy Expiration Date
-
Month
-
Day
Year
Date
Group Health Insurance Carrier
*
Type (NA) if you have no current policy.
Current Policy Expiration Date
-
Month
-
Day
Year
Date
Group Life Insurance Carrier
*
Type (NA) if you have no current policy.
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
Do you wish to offer a 401k plan?
*
Yes
No
Do you currently have a qualified payroll program?
*
Yes
No
Other
If you have a qualified payroll program, do you offer direct deposit?
*
Yes
No
Other
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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 ($)
Building Property Value ($)
Building Property Value ($)
Personal Property Value ($)
Annual Gross Revenue ($)
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GENERAL LIABILITY
Are you requesting General Liability Coverage
*
Yes
No
Desired Amount of General Liability Coverage ($)
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?
Do you have business tools or equipment to insure?
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 ($)
Describe Professional Services offered?
Does your firm provide services outside the U.S.?
Yes
No
Percentage of Services for the outside the U.S
Is there a formal Safety Plan?
Yes
No
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
What is the percentage of your firm’s gross Fees paid to ICs or Sub Contractors last year?
Rows
Yes
No
Do you request Certificates of Insurance from ICs and Sub Contractors?
Do you have written agreements on every project?
Do ICs and Sub Contractors have written agreements?
Do you provide Professional Liability to your ICs and Sub Contractors?
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Medical Professional Liability
Are you requesting Medical Professional Liability Coverage?
*
Yes
No
Desired Amount of Professional Liability Coverage ($)
Describe Professional Services offered
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
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 ($)
Signature
*
Submit
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