Language
English (US)
Spanish (Latin America)
Staff Name
Commercial Insurance Questionnaire
General Information
Applicant's Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Email
example@example.com
Contact Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company's name
Legal Entity
Nonprofit
Corporation
Partnership
Individual
LLC
Other
FEIN
Year of experience
Business established date (year)
Number of employees
Detailed information about your business
Gross Annual Revenue ($)
Insurance coverage requested
General Liability
Commercial Auto
Workers' compensation
Business Owner Policy (BOP)
Professional Liabilty
Other
Current Insurance Carrier
Current Policy Expiration Date
-
Month
-
Day
Year
Date
Desired Effective Date for New Policy
-
Month
-
Day
Year
Date
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Property Insurance
Are you requesting Property Coverage
Yes
No
If yes, please fill out this section about building information
Construction Type
Please Select
fire-resistive
non-combustible
ordinary
heavy timber
wood-framed
other
Year Built
Sq feet
Roof age
Equipment Value ($)
Amount of inventory ($)
Tenant Betterment and Improvements ($ spent on improvements-space. ex floor, drywall)
Cameras?
Yes
No
Workers' Compensation
Are you requesting Workers’ Compensation Coverage?
Yes
No
Total Estimated Payroll ($)
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Commercial Auto
Driver 1
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Driver 2
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
VIN 1
Type of coverage
Please Select
Full Coverage
Liability
VIN 2
Type of coverage
Please Select
Full Coverage
Liability
Submit
Should be Empty: