Commercial Insurance Questionnaire

Page 1

Applicant Name

First Name

Last Name

Email

Contact Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Company Name

Business established date

FEIN

SIC Code

Number of employees

Detailed information about your business

Gross Annual Payroll ($)

Gross Annual Revenue ($)

Insurance coverage requested

Property General Liability Professional Liability Workers' Compensation Commercial Auto

Current Insurance Carrier

Current Policy Expiration Date

Current Policy Retroactive Date

Desired Effective Date for New Policy

Page 2

Are you requesting Property Coverage

Yes No

List the current carrier

Construction Type

Year Built

Insured sq feet

Unoccupied sq feet

Building Property Value ($)

Personal Property Value ($)

Annual Gross Revenue ($)

Page 3

Page 4

Are you requesting Professional Liability Coverage?

Yes No

Desired Amount of Professional Liability Coverage ($)

Describe Professional Services offered?

Does your firm provide services outside the U.S.?

Yes No

Percentage of Services for the outside the U.S

Is there a formal Safety Plan?

Yes No

Does your firm use Independent Contractors (ICs) or Sub Contractors?

Yes No

What is the percentage of your firm's gross Fees paid to ICs or Sub Contractors last year?

Page 5

Are you requesting Medical Professional Liability Coverage?

Yes No

Desired Amount of Professional Liability Coverage ($)

Describe Professional Services offered

Does your firm use Independent Contractors (ICs) or Sub Contractors?

Yes No

Page 6

Are you requesting Workers' Compensation Coverage?

Yes No

Are Medical Benefits Offered?

Yes No

Do you offer Paid Vacation?

Yes No

Is there a formal Safety Program?

Yes No

Total Estimated Payroll ($)

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Commercial Insurance Questionnaire

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