Client Information
Owner's Name
Title
Email
Phone
Business Information
Business Name
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Webpage
FEIN/TAX ID Number
Company Size
Please Select
1-10 Employees
10-50 Employees
50-100 Employees
over 100 employees
Type of Business
Years of Experience
Annual Sales for the Business
Business Policy Attachment
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List Any Additional Location Address:
Have you ever had an insurance policy non-renewal, cancelled, or declined?
Have you ever been convicted of a crime of fraud, bribery, or arson?
Any bankruptcies, tax or credit liens?
Are there any additional insured's?
coverages
Select desired coverage's below
General Liability Coverage
Annual Gross Receipts:
Total Number of Employees:
Annual Payroll:
Are subcontractors being used? What are their duties and how much do you spend on subcontractors annually?
Please describe the business:
Any foreign operations?
Is the business currently insured?
Any claims in the last 5 years?
Is a Wavier of Subornation or Additional Insured's needed to be listed?
Do you lease space to others?
Type a question
Property Coverage
Is the entity the building owner or tenant?
What year was the building built?
Construction type of building and roof?
Size and Square Feet of building and when was it built?
Sq Feet And Year Built
Does it have a monitored burglar or fire alarm?
Does the building have a sprinkler system?
How much would it cost to replace all the property inside the building?
Is any space leased out?
Are tenants you lease to required to list you as additional insured on their insurance?
Please describe any property claims in the last 5 years.
Type a question
Commercial Auto Coverage
How many vehicles do you have?
Do employees take any vehicles home?
Garage Locations
Copy of Driver's list (include names, date of birth and driver license numbers), Copy of Vehicles List: Year, Make, Model and VIN#.
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Description of what vehicles are used for:
Describe any auto claims in the last 5 years:
Type a question
Umbrella Coverage
Do you have a commercial umbrella?
How much coverage do you think you need?
Type a question
Workers Compensation Coverage
List Owners and Payroll for each:
List of Employees with Annual Payroll and Each Employees Occupation and Duties:
Do you use subcontractors? if Yes, What percentage of Annual gross income is spent on subcontractors?
Have you had any claims? If Yes, Please give Description:
Do you give permission for Lomax Financial Group to process the insurance quote for you, with the information you have provided ?
Yes
no
Signature
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