Commercial Survey

(Please enter a 0 for the questions that do not apply)

Survey Date

MonthDayYear

Completed by

First NameLast Name

Name on Policy

Policy #

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

During the last policy period, what were your total receipts for:

Caterting:

US Dollars

Food Sold:

US Dollars

Alcohol Sold:

US Dollars

All other Products Sold:

US Dollars

Other Operations Performed:

US Dollars

During the last policy period:

What was your total payroll:

US Dollars

How many people do you employ Full time?

How many people do you employ Part time?

During the last policy period:

Did you begin any new type of work?

YesNo

Did you begin any new type of off premise activity?

YesNo

Did you begin any new type of operations?

YesNo

Did you open any new locations?

YesNo

If yes, to any of the above questions, please explain:

During the last policy period:

Did you hire any contractor/subcontractor

YesNo

Total cost of contract

If yes, describe the type of work performed:

Did the contractor provide his/her own general liability & worker's compensation?

YesNo

If yes, what is the name of the insurance company?

If work is still in progress, please submit certificates of insurance for general liability and worker's compensation insuring the contractor.

Additional Survey Comments/Questions:

IMPORTANT NOTICE TO POLICYHOLDER

"Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."

As part of our underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living. A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal, or extension of the insurance to which this application is made. The applicant, upon written request, will be informed whetheror not a consumer report was requested - and if such was requested, informed of the name and address of the consumer reporting agency that furnished the report. The person completing this survey hereby affirms that the statements and representations made herein are true to the best of his/her knowledge.