Commercial Questionnaire Form – Fill Out and Use This PDF

COMMERCIAL INSURANCE QUESTIONNAIRE

Please complete the information below. IMPORTANT: This form is not an insurance policy – it is general information necessary to prepare a quotation. Note that many carriers require a complete signed carrier application specific to their product offerings.

GENERAL INFORMATION

Applicant Name: ____________________________________________________________________

Business Name: ____________________________________________________________________

DBA (if applicable): __________________________________________________________________

Mailing Street Address: _______________________________________________________________

City: ________________________ County: __________________ State: ______ Zip: __________

Phone: __________ Fax: __________ Email: ___________________________________________

Location Street Address: ______________________________________________________________

City: ________________________ County: __________________ State: ______ Zip: ___________

Principal Contact Name: __________________________________

Phone: __________			Email: __________________________________________
Legal Entity (Check one):
Corporation	LLC	Partnership	Individual	Not For Profit	Other (please specify):

Date Business Established: ___________

FEIN: ___________

SIC Code: __________

Years in Operation: ____________

Years of Owner Experience in Industry: _____

Description of Operations (Min. 10 Words): ________________________________________________

Number of Employees:
Full Time ________ Part Time ________
Gross Annual Payroll: $____________
Gross Annual Revenue: $____________
Insurance Coverage Requested (Check all that apply):
Business Owners Policy (BOP)	General Liability	Professional Liability
Commercial Auto	Workers’ Comp	Other

Current Insurance Carrier (If no insurance, enter “NONE”): ____________________________________

Current Policy Expiration Date: ___________

Current Policy Retroactive Date: ___________

Current Limits: ___________

Desired Effective Date for New Policy: ___________

Desired Limits: ___________

Desired Deductible: ___________

	PROPERTY DETAILS
Are you requesting Property Coverage	Yes	No

If no, list the current carrier - if no current insurance, enter “NONE”. _____________________________

Is there Boiler Machinery Coverage Exposure	Yes	No
Is there Earthquake Sprinkler Leakage Exposure	Yes	No
Is there Underground Tank Leakage Exposure	Yes	No
Do employees handle cash	Yes	No

Location 1 Street Address: _____________________________________________________________

City: ________________________ County: __________________ State: ______ Zip: ___________

Building Information
Insured sq feet: ______	Occupied sq feet: ______ Unoccupied sq feet: ______ Total: ______

Describe other occupancies: _______________________________________________________________

_______________________________________________________________________________________

Construction Type: ___________________			Number of stories: ______ % Sprinklered: ______
Building within city limits:	Yes		No
Year Built: ________
Year Renovated (Mandatory if building is greater than 10 years old):
Roof _______		Electrical _______ Plumbing _______		Heating/AC _______

Property Values
Building: ____________	Personal Property: ____________ Stock: ____________
Business Income
Annual Gross Revenue: ____________		Estimate Annual Payroll: ____________

Complete the Property section above for all additional locations.

GENERAL LIABILITY
Are you requesting General Liability Coverage:	Yes	No

If no, list the current carrier - if no current insurance, enter “NONE”. _____________________________

Desired Amount of General Liability Coverage: ___________________
Are Professional Services offered:	Yes	No

If yes, describe (Min. 10 Words): _________________________________________________________

_______________________________________________________________________________________

Are any autos used exclusively for business use	Yes	No
Do any employees use a personal auto for business use	Yes	No
Are any web based services offered	Yes	No
Are credit card payments accepted	Yes	No
Is there a program to identify identity theft	Yes	No
Is there Underground Tank Leakage Exposure	Yes	No
Is there a Pollution Exposure	Yes	No

PROFESSIONAL LIABILITY
Are you requesting Professional Liability Coverage:	Yes	No

If no, list the current carrier - if no current insurance, enter “NONE”. _____________________________

Desired Amount of Professional Liability Coverage: ___________________

Describe Professional Services offered: (Min. 10 Words): _________________________________________

_______________________________________________________________________________________

Does your firm provide services outside the U.S.				Yes	No
Percentage of Services:	______% US		______% Foreign
Does your firm use Independent Contractors (ICs) or Sub Contractors				Yes	No
Full Time __________		Part Time __________
Is there a formal Safety Plan:				Yes	No
What is the percentage of your firm’s gross Fees paid to ICs or Sub Contractors last year:
Do you request Certificates of Insurance from ICs and Sub Contractors:				Yes	No
Do you have written agreements on every project:				Yes	No
Do ICs and Sub Contractors have written agreements:				Yes	No
Do you provide Professional Liability to your ICs and Sub Contractors:				Yes	No

ALLIED MEDICAL AND MEDICAL PROFESSIONAL LIABILITY
Are you requesting Allied Medical Professional Liability Coverage:	Yes	No

If no, list the current carrier - if no current insurance, enter “NONE”. _____________________________

Desired Amount of Professional Liability Coverage: ___________________

Describe Professional Services offered: (Min. 10 Words): _________________________________________

_______________________________________________________________________________________

Does your firm use Independent Contractors (ICs) or Sub Contractors		Yes	No
Full Time __________	Part Time __________

WORKERS' COMPENSATION
Are you requesting Workers’ Compensation Coverage:	Yes	No

If no, list the current carrier - if no current insurance, enter “NONE”. _____________________________

Number of Employees:
Full Time ______	Part Time ______ Volunteer ______	TOTAL ______
Number of Independent Contractors (ICs):
Full Time ______	Part Time ______
Are Medical Benefits Offered		Yes	No
Do you offer Paid Vacation		Yes	No
Is there a formal Safety Program		Yes	No

Total Estimated Payroll: $____________

Payroll Information:

	# Employees
Class Code, Duties, or Description	FT	PT		Estimated Payroll

For the Payroll Information section above for all locations

ADDITIONAL COVERAGE INTERESTS