Commercial Insurance Questionnaire

1
Applicant Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Contact Number * This field is required.
Please enter a valid phone number.
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Company Name* This field is required.
6
Legal Entity* This field is required.
Nonprofit
Corporation
Partnership
Individual
LLC
Other
7
Business established date* This field is required.
Date
Month
Day
Year
8
Number of employees* This field is required.
9
Detailed informations about your business
10
Gross Annual Payroll ($)
11
Gross Annual Revenue ($)
12
Insurance coverage requested* This field is required.
Business Owner Policy (BOP)
Commercial Auto
General Liability
Professional Liabilty
Workers' compensation
Other
13
Current Insurance Carrier* This field is required.
14
Current Policy Expiration Date* This field is required.
Date
Month
Day
Year
15
Current Policy Retroactive Date* This field is required.
Date
Month
Day
Year
16
Desired Effective Date for New Policy* This field is required.
Date
Month
Day
Year
17
Are you requesting Property Coverage
Yes
No
18
List the current carrier
19
Construction Type
Please Select
Please Select
fire-resistive
non-combustible
ordinary
heavy timber
wood-framed
other
20
Year Built
21
Insured sq feet
22
Unoccupied sq feet
23
Year Renovated
Renovated Year
Roof
Row 0, Column 0
Electrical
Row 1, Column 0
Plumbing
Row 2, Column 0
Heating
Row 3, Column 0
Roof
Electrical
Plumbing
Heating
Renovated Year
Row 0, Column 0
Renovated Year
Row 1, Column 0
Renovated Year
Row 2, Column 0
Renovated Year
Row 3, Column 0
1 of 4
24
Building Security
Local
Central
None
Fire Alarm
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Burglar Alarm
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Fire Alarm
Burglar Alarm
Local
Row 0, Column 0
Central
Row 0, Column 1
None
Row 0, Column 2
Local
Row 1, Column 0
Central
Row 1, Column 1
None
Row 1, Column 2
1 of 2
25
Building Property Value ($)
26
Personal Property Value ($)
27
Annual Gross Revenue ($)
28
Are you requesting General Liability Coverage
Yes
No
29
Desired Amount of General Liability Coverage ($)
30
Type a question
Yes
No
Are any autos used exclusively for business use?
Row 0, Column 0
Row 0, Column 1
Do any employees use a personal auto for business use?
Row 1, Column 0
Row 1, Column 1
Are any web based services offered?
Row 2, Column 0
Row 2, Column 1
Are credit card payments accepted?
Row 3, Column 0
Row 3, Column 1
Is there a program to identify identity theft?
Row 4, Column 0
Row 4, Column 1
Is there Underground Tank Leakage Exposure?
Row 5, Column 0
Row 5, Column 1
Is there a Pollution Exposure?
Row 6, Column 0
Row 6, Column 1
Are any autos used exclusively for business use?
Do any employees use a personal auto for business use?
Are any web based services offered?
Are credit card payments accepted?
Is there a program to identify identity theft?
Is there Underground Tank Leakage Exposure?
Is there a Pollution Exposure?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
1 of 7
31
Are you requesting Professional Liability Coverage?
Yes
No
32
Desired Amount of Professional Liability Coverage ($)
33
Describe Professional Services offered?
34
Does your firm provide services outside the U.S.?
Yes
No
35
Percentage of Services for the outside the U.S
36
Is there a formal Safety Plan?
Yes
No
37
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
38
What is the percentage of your firm’s gross Fees paid to ICs or Sub Contractors last year?
39
Type a question
Yes
No
Do you request Certificates of Insurance from ICs and Sub Contractors?
Row 0, Column 0
Row 0, Column 1
Do you have written agreements on every project?
Row 1, Column 0
Row 1, Column 1
Do ICs and Sub Contractors have written agreements?
Row 2, Column 0
Row 2, Column 1
Do you provide Professional Liability to your ICs and Sub Contractors?
Row 3, Column 0
Row 3, Column 1
Do you request Certificates of Insurance from ICs and Sub Contractors?
Do you have written agreements on every project?
Do ICs and Sub Contractors have written agreements?
Do you provide Professional Liability to your ICs and Sub Contractors?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
1 of 4
40
Are you requesting Medical Professional Liability Coverage?
Yes
No
41
Desired Amount of Professional Liability Coverage ($)
42
Describe Professional Services offered
43
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
44
Type a question
Yes
No
Do you employ Physicians or Surgeons?
Row 0, Column 0
Row 0, Column 1
Is there a Medical Director?
Row 1, Column 0
Row 1, Column 1
Does the Medical Director have their own insurance?
Row 2, Column 0
Row 2, Column 1
Do you request Certificates of Insurance from ICs and Sub Contractors?
Row 3, Column 0
Row 3, Column 1
Do you have written agreements on every project?
Row 4, Column 0
Row 4, Column 1
Do ICs and Sub Contractors have written agreements?
Row 5, Column 0
Row 5, Column 1
Do you provide Professional Liability to your ICs and Sub Contractors?
Row 6, Column 0
Row 6, Column 1
Do you bill for Medicare/Medicaid?
Row 7, Column 0
Row 7, Column 1
Do you employ Physicians or Surgeons?
Is there a Medical Director?
Does the Medical Director have their own insurance?
Do you request Certificates of Insurance from ICs and Sub Contractors?
Do you have written agreements on every project?
Do ICs and Sub Contractors have written agreements?
Do you provide Professional Liability to your ICs and Sub Contractors?
Do you bill for Medicare/Medicaid?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
Yes
Row 7, Column 0
No
Row 7, Column 1
1 of 8
45
Are you requesting Workers’ Compensation Coverage?
Yes
No
46
Number of Employees
Full-time
Part-time
Number of Employees
Row 0, Column 0
Row 0, Column 1
Number of Employees
Full-time
Row 0, Column 0
Part-time
Row 0, Column 1
47
Number of Independent Contractors (ICs)
Full-time
Part-time
Number of Independent Contractors (ICs)
Row 0, Column 0
Row 0, Column 1
Number of Independent Contractors (ICs)
Full-time
Row 0, Column 0
Part-time
Row 0, Column 1
48
Are Medical Benefits Offered?
Yes
No
49
Do you offer Paid Vacation?
Yes
No
50
Is there a formal Safety Program?
Yes
No
51
Total Estimated Payroll ($)
Should be Empty: