Commercial Insurance Questionnaire

Page 1

Applicant name

Nombre

Apellido

Email

Contact number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Company name

Legal entity

Sole proprietorship Partnership Limited liability company Corporation Non-profit organisation

Business established date

FEIN

SIC code

Number of employees

Detailed information about your business

Gross annual payroll ($)

Gross annual revenue ($)

Insurance coverage requested

General liability Property Professional liability Commercial auto Workers' compensation Inland marine Umbrella

Current insurance carrier

Current policy expiration date

Current policy retroactive date

Desired effective date for the new policy

Page 2

Are you requesting property coverage?

Yes No

List the current carrier

Construction type

Year built

Insured square feet

Unoccupied square feet

Building property value 1 ($)

Building property value 2 ($)

Building property value 3 ($)

Personal property value ($)

Annual gross revenue for the location ($)

Page 3

Are you requesting general liability coverage?

Yes No

Desired amount of general liability coverage ($)

Page 4

Are you requesting professional liability coverage?

Yes No

Desired amount of professional liability coverage ($)

Describe the professional services you offer

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

Yes No

Percentage of services provided outside the U.S.

Is there a formal safety plan?

Yes No

Does your firm use independent contractors or subcontractors?

Yes No

Percentage of gross fees paid to contractors last year

Page 5

Are you requesting commercial auto coverage?

Yes No

Do any employees use personal vehicles for business?

Yes No

Page 6

Are you requesting inland marine insurance?

Yes No

For contractors: average size of a typical job

For contractors: largest job in the last 12 months

For contractors: value of tools not listed above

Page 7

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 ($)

Page 8

Are you requesting a commercial umbrella policy?

Yes No

What limit are you interested in buying?

Page 9

Page 10

Supporting documents

Please attach your files here

Max 10 MB per file

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Commercial Insurance Questionnaire

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