Commercial Insurance Questionnaire

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Commercial Insurance Questionnaire

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

First Last

Business Name

DBA (if applicable)

Phone

Fax

Principal Contact Name

First Last

Principal Contact Phone

Principal Contact Email

Mailing Address

Street Address City State ZIP Code

Physical Address

Street Address City State ZIP Code

Legal Entity

Date Business Established

Years in Operation

FEIN

SIC Code

Years of Owner Experience in Industry

Description of Operations

One to two sentences describing the operation of the business.

Number of Full-Time Employees

Number of Part-Time Employees

Gross Annual Payroll

Gross Annual Revenue

Coverage Request

Insurance Coverage Requested (Check all that apply)

Business Owners Policy

(BOP) General Liability

Professional Liability

Commercial Property

Commercial Auto

Workers’ Comp

Medical Professional Liability

Other

Other Insurance Coverage Request:

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

Commercial Property

Current Carrier (If no Current Insurance enter NONE)

How Many Properties?

A representative will call to gather all the details for your custom quote

Property #1

Is there Underground Tank Leakage Exposure

Yes

Is there Earthquake Sprinkler Leakage Exposure

Yes

Is there Boiler Machinery Coverage Exposure

Yes

Do employees handle cash

Yes

Building Ownership (Check one):

Owned

Leased

Triple Net Lease

Covered Property Physical Address

Street Address Address Line 2 City State ZIP Code

Building Insured Sq Ft

Building Occupied Sq Ft

Building Unoccupied Sq Ft

Building Total Sq Ft

Other Occupancies

Describe any other occupancies if applicable.

Construction Type

Number of Stories

Percentage Sprinklered

Is the Building Located within City Limits?

Yes

Year Built

Please enter a number from 1850 to 2030.

What Year Was Each Renovated. Required if the building is greater than 10 years old.

Roof

Electrical

Heating/AC

Plumbing

Building Security

Fire Alarm

None

Local

Central

Smoke Detectors

None

Battery

Hardwired

Burglar Alarm

None

Local

Central

Property Values

Building:

Personal Property:

Stock:

This Location Annual Gross Revenue

This Location Annual Estimated Payroll

Property #2

Is there Underground Tank Leakage Exposure

Yes

Is there Earthquake Sprinkler Leakage Exposure

Yes

Is there Boiler Machinery Coverage Exposure

Yes

Do employees handle cash

Yes

Building Ownership (Check one):

Owned

Leased

Triple Net Lease

Covered Property Physical Address

Street Address Address Line 2 City State ZIP Code

Building Insured Sq Ft

Building Occupied Sq Ft

Building Unoccupied Sq Ft

Building Total Sq Ft

Other Occupancies

Describe any other occupancies if applicable.

Construction Type

Number of Stories

Percentage Sprinklered

Is the Building Located within City Limits?

Yes

Year Built

Please enter a number from 1850 to 2030.

What Year Was Each Renovated. Required if the building is greater than 10 years old.

Roof

Electrical

Heating/AC

Plumbing

Building Security

Fire Alarm

None

Local

Central

Smoke Detectors

None

Battery

Hardwired

Burglar Alarm

None

Local

Central

Property Values

Building:

Personal Property:

Stock:

This Location Annual Gross Revenue

This Location Annual Estimated Payroll

Property #3

Is there Underground Tank Leakage Exposure

Yes

Is there Earthquake Sprinkler Leakage Exposure

Yes

Is there Boiler Machinery Coverage Exposure

Yes

Do employees handle cash

Yes

Building Ownership (Check one):

Owned

Leased

Triple Net Lease

Covered Property Physical Address

Street Address Address Line 2 City State ZIP Code

Building Insured Sq Ft

Building Occupied Sq Ft

Building Unoccupied Sq Ft

Building Total Sq Ft

Other Occupancies

Describe any other occupancies if applicable.

Construction Type

Number of Stories

Percentage Sprinklered

Is the Building Located within City Limits?

Yes

Year Built

Please enter a number from 1850 to 2030.

What Year Was Each Renovated. Required if the building is greater than 10 years old.

Roof

Electrical

Heating/AC

Plumbing

Building Security

Fire Alarm

None

Local

Central

Smoke Detectors

None

Battery

Hardwired

Burglar Alarm

None

Local

Central

Property Values

Building:

Personal Property:

Stock:

This Location Annual Gross Revenue

This Location Annual Estimated Payroll

Property #4

Is there Underground Tank Leakage Exposure

Yes

Is there Earthquake Sprinkler Leakage Exposure

Yes

Is there Boiler Machinery Coverage Exposure

Yes

Do employees handle cash

Yes

Building Ownership (Check one):

Owned

Leased

Triple Net Lease

Covered Property Physical Address

Street Address Address Line 2 City State ZIP Code

Building Insured Sq Ft

Building Occupied Sq Ft

Building Unoccupied Sq Ft

Building Total Sq Ft

Other Occupancies

Describe any other occupancies if applicable.

Construction Type

Number of Stories

Percentage Sprinklered

Is the Building Located within City Limits?

Yes

Year Built

Please enter a number from 1850 to 2030.

What Year Was Each Renovated. Required if the building is greater than 10 years old.

Roof

Electrical

Heating/AC

Plumbing

Building Security

Fire Alarm

None

Local

Central

Smoke Detectors

None

Battery

Hardwired

Burglar Alarm

None

Local

Central

Property Values

Building:

Personal Property:

Stock:

This Location Annual Gross Revenue

This Location Annual Estimated Payroll

Property #5

Is there Underground Tank Leakage Exposure

Yes

Is there Earthquake Sprinkler Leakage Exposure

Yes

Is there Boiler Machinery Coverage Exposure

Yes

Do employees handle cash

Yes

Building Ownership (Check one):

Owned

Leased

Triple Net Lease

Covered Property Physical Address

Street Address Address Line 2 City State ZIP Code

Building Insured Sq Ft

Building Occupied Sq Ft

Building Unoccupied Sq Ft

Building Total Sq Ft

Other Occupancies

Describe any other occupancies if applicable.

Construction Type

Number of Stories

Percentage Sprinklered

Is the Building Located within City Limits?

Yes

Year Built

Please enter a number from 1850 to 2030.

What Year Was Each Renovated. Required if the building is greater than 10 years old.

Roof

Electrical

Heating/AC

Plumbing

Building Security

Fire Alarm

None

Local

Central

Smoke Detectors

None

Battery

Hardwired

Burglar Alarm

None

Local

Central

Property Values

Building:

Personal Property:

Stock:

This Location Annual Gross Revenue

This Location Annual Estimated Payroll

Property #6

Is there Underground Tank Leakage Exposure

Yes

Is there Earthquake Sprinkler Leakage Exposure

Yes

Is there Boiler Machinery Coverage Exposure

Yes

Do employees handle cash

Yes

Building Ownership (Check one):

Owned

Leased

Triple Net Lease

Covered Property Physical Address

Street Address Address Line 2 City State ZIP Code

Building Insured Sq Ft

Building Occupied Sq Ft

Building Unoccupied Sq Ft

Building Total Sq Ft

Other Occupancies

Describe any other occupancies if applicable.

Construction Type

Number of Stories

Percentage Sprinklered

Is the Building Located within City Limits?

Yes

Year Built

Please enter a number from 1850 to 2030.

What Year Was Each Renovated. Required if the building is greater than 10 years old.

Roof

Electrical

Heating/AC

Plumbing

Building Security

Fire Alarm

None

Local

Central

Smoke Detectors

None

Battery

Hardwired

Burglar Alarm

None

Local

Central

Property Values

Building:

Personal Property:

Stock:

This Location Annual Gross Revenue

This Location Annual Estimated Payroll

General Liability

Current Carrier (If no Current Insurance enter NONE)

Desired Amount of General Liability Coverage:

Are Professional Services offered:

Yes

Please describe the professional services offered:

Are any vehicles used exclusively for business use?

Yes

Do any employees use a personal vehicle for business use?

Yes

Are any web-based services offered?

Yes

Are credit card payments accepted?

Yes

Is there a program to identify identity theft?

Yes

Is there Underground Tank Leakage Exposure?

Yes

Is there a Pollution Exposure?

Yes

Professional Liability

Current Carrier (If no Current Insurance enter NONE)

Desired Amount of General Liability Coverage:

Please describe the professional services offered:

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

Yes

What Percentage?

Is US Based

Please enter a number less than or equal to 100.

What Percentage?

Is Foreign Based

Please enter a number less than or equal to 100.

Do you have written agreements on every project?

Yes

Is there a formal Safety Plan?

Yes

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

Yes

What Percentage?

Full Time

Please enter a number less than or equal to 100.

What Percentage?

Part Time

Please enter a number less than or equal to 100.

What is the percentage of your firm’s gross fees paid to ICs or Subcontractors last year??

Please enter a number less than or equal to 100.

Do you request Certificates of Insurance from ICs and Subcontractors?

Yes

Do ICs and Subcontractors have written agreements?

Yes

Do you provide Professional Liability to your ICs and Subcontractors?

Yes

Do you employ Physicians or Surgeons?

Yes

Is there a Medical Director?

Yes

Does the Medical Director have their own insurance?

Yes

Workers' Compensation

Current Carrier (If no Current Insurance enter NONE)

Number of Full Time Employees

Number of Part Time Employees

Number of Volunteers

Total

Number of Full Time Independent Contractors (ICs)

Number of Part Time Independent Contractors (ICs)

Total

Are Medical Benefits Offered?

Yes

Is there a formal Safety Program?

Yes

Do you offer Paid Vacation?

Yes

Payroll Information

Include all locations

Class Code/Duties

Full Time Or Part Time

Estimated Payroll

Employees/Owners to be Excluded

Name

Title

Estimated Payroll

Total Estimated Payroll

Calculate from above

Additional Coverage Options

Check all that apply

Other Additional Coverage Desired:

Medical Professional Liability

Current Carrier (If no Current Insurance enter NONE)

Number of Employees

Desired Amount of Professional Liability Coverage

Describe Professional Services Offered:

Do you have written agreements on every project?

Yes

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

Yes

What Percentage?

Full Time

Please enter a number less than or equal to 100.

What Percentage?

Part Time

Please enter a number less than or equal to 100.

Do you request Certificates of Insurance from ICs and Subcontractors?

Yes

Do ICs and Subcontractors have written agreements?

Yes

Do you provide Professional Liability to your ICs and Subcontractors?

Yes

Do you employ Physicians or Surgeons?

Yes

Is there a Medical Director?

Yes

Does the Medical Director have their own insurance?

Yes

Do you bill for Medicare/Medicaid?

Yes

Commercial Insurance Questionnaire

General Information

Coverage Request

Commercial Property

Property #1

Property #2

Property #3

Property #4

Property #5

Property #6

General Liability

Professional Liability

Workers' Compensation

Medical Professional Liability

Turning Risk into Opportunity

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