Website - Commercial Questionnaire

Anchor Insurance Agency Commercial Questionnaire

Please provide your business details to help us better understand your operations and needs.
Current declarations page

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Requested Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Coverage(s) Requested
Legal Business Name
DBA (Doing Business As), if applicable
Business Entity Type
Year Established
Business Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Additional Locations (if any)
Type of Business / Describe Operations
Annual Gross Revenue
Number of Employees (Full-time)
Number of Employees (Part-time)
Primary Contact Name

First NameLast Name
Primary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Email
example@example.com
Owner/Principal Name(s)
Owner Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Insurance Carrier
Insurance Policy Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Shopping / Making a Change
Property Details
Own or Lease the Building
Building Square Footage
Year Built
Construction Type
Roof Type
Roofing – Year Last Updated
Plumbing – Year Last Updated
Electrical – Year Last Updated
Heating/HVAC – Year Last Updated
Number of Stories
Business Personal Property Value
Burglar Alarm
Fire Alarm
Sprinkler System
Liability Details
Estimated Annual Gross Sales/Receipts
Square Footage Occupied
Do You Use Subcontractors?
Do You Collect Certificates of Insurance from Subcontractors?
Loss History
Any claims or losses in the past 5 years?
If Yes, list each claim with date, type, amount paid, and open/closed status
Loss Runs

(claims history report from your current carrier)
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Should be Empty:

Anchor Insurance Agency Commercial Questionnaire

Property Details

Liability Details

Loss History