• Commercial Insurance Quote Questionnaire

    Complete this questionnaire to help David Williams Insurance Agency quote your business coverage—confirm any prefilled details and answer required questions as accurately as possible.

  • Business Information

  • Format: (000) 000-0000.
  • Requested policy effective date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Which coverages would you like quoted?*
  • Does the business own any vehicles?
  • Does the business currently have an umbrella policy?
  • Does the business collect or store sensitive customer information?
  • What is your main goal for this quote?
  • Do you have insurance requirements from a lender, landlord, or vendor?
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  • Current Insurance and Claims History

  • Current Policy Expiration Date
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Have there been any property or liability claims in the last five years?
  • Any lapse in property or liability coverage in the last five years?
  • Most carriers require five years of claims history (loss runs). We can request them from your insurance company for you. We'll email an authorization for you to sign electronically.

  • Additional Interests

    Many landlords, lenders, contractors, and vendors require being listed on your policy. Tell us about anyone who needs to be named.
  • Many landlords, lenders, contractors, and vendors require being listed on your policy. Tell us about anyone who needs to be named.
  • Does anyone need to be listed as an additional insured on your policy?
  • Additional insureds
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  • Property manager details are on the Additional Interests page.
  • Lenders / mortgagees
  • Is the property managed by a property manager or management company?
  • Format: (000) 000-0000.
  • Should the property manager be listed as an additional insured?
  • Is there a lender, mortgage, or loan on the property, building, or equipment being insured (including a lessor's risk property)?

  • Commercial Auto

  • Drivers
  • For your security, we'll collect each driver's license number and date of birth separately by phone or secure upload, not on this form.
  • Vehicles

  • Commercial Property

  • Is the property owned or leased?
  • Any units currently vacant?
  • Sprinkler system
  • Burglar alarm or security system
  • Fire alarm system
  • Do you own or are you responsible for any parking spaces or lots?
  • Parking spaces or lots are
  • Have more than one location? We'll send a separate location supplement.

  • Workers' Compensation

  • Currently have workers' compensation insurance?
  • Policy expiration date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Any lapses in workers' compensation coverage in the last 5 years?
  • Employee breakdown by job duties
  • Any employees working remotely or from home?
  • Any employees working outside California?
  • If yes, list other states, number of employees, and payroll by state
  • Do employees work at customer or off-site locations?
  • Does the business use subcontractors or independent contractors?
  • If yes, subcontractor or independent contractor details
  • Does the business use temporary or staffing agency employees?
  • Any workers' compensation claims in the last 5 years?
  • If yes, claim details
  • Does the business have an experience modification rate (X-Mod)?
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  • Currently on a pay-as-you-go workers' compensation program?
  • Preferred billing method if available
  • Are there specific workers' compensation requirements from a landlord, general contractor, or vendor?
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  • Review and Submit

  • Do you regularly provide certificates of insurance (COIs) to customers, general contractors, or vendors? For example, contractors who work at different job sites, or businesses with repeat customers who require a certificate.
  • Certificate holders
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  • Should be Empty: