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Business Insurance Questionnaire
Call Us Today At
(281) 550-5864
Business Insurance Questionnaire
Legal Name of Business
DBA
(FEIN) Tax ID
Owner Name
Title
Main Contact
Business Phone
*
Mobile Phone
Fax
Email
Website Address
Physical Address
Mailing Address
Date Business Started
Proposed Effective Date
Please indicate your preferred method of communication:
Voice / Phone
Fax
Email
Text
Legal Structure of Business Entity
Association
Corporation
Government Entity
Individual / Sole Proprietor
Limited Liability Company ( LLC )
Limited Liability Partnership (LLP)
Non Profit
Partnership
Professional Corporation
Subchapter S
Join Venture
Trust
Trustee
Detailed Description of Business
General Information
Annual revenue (Approximate)
Annual payroll (Approximate)
Approx. total annual payroll for clerical work only
If you own and operate any other business under the same legal entity, please give a detailed description
What Is The Nature Of The Business:
Apartments
Condominiums
Contractor
Institutional
Manufacturing
Office
Restaurant
Retail
Service
Wholesale
State of Incorporation
Business Category Classification
NACS Code:
GL Code:
SIC Code:
What percentage (%) of total sales/revenues does each account for?
Residential:
Commercial:
hat percentage (%) of total sales/revenues does each account for?
Service: %
Install: %
Repair: %
Sales: %
Is your company a subsidiary of another entity?
Yes
No
Parent company name
Relationship
Percentage owned
Does your company have any subsidiaries?
Yes
No
Subsidiary company name
Relationship
Percentage owned
Does your company have any exposure to flammables, explosives, or chemicals?
Yes
No
Please explain:
Has your company policy or coverage cancelled or non renewed in the last three years?
Yes
No
If yes, cancelled for the following reasons
Non-Payment
Non-Renewal
Agent no longer representing carrier
Underwriting
If cancelled for underwriting has condition been resolved?
Yes
No
Any past, loss or claims relating to sexual abuse or molestation allegations, discrimination, or negligent hiring?
Yes
No
Please explain:
During the last 5 years have you or your company been indicted or convicted of any degree of the crime of fraud, bribery, arson, or any other arson related crime in connection with this or any other property?
Yes
No
Please explain:
Does your company currently have any uncorrected fire and or safety code violations?
Yes
No
If yes:
Occur date
Explanation
Resolution
Resolve date
Has any applicant had a repossession, bankruptcy, or filed for bankruptcy in the last 5 years?
Yes
No
If yes:
Occur date
Explanation
Resolution
Resolve date
Has you company had a judgement or lien filed against it in the last 5 years?
Yes
No
If yes:
Occur date
Explanation
Resolution
Resolve date
Has your company been placed in a trust?
Yes
No
Name of trust:
Does your company have other ventures which coverage is not requested?
Yes
No
Please give details:
Does your company own / lease / operate any drones?
Yes
No
Please give details:
Does your company hire others to operate drones?
Yes
No
Please give details:
Who is your current carrier?
Expiration date for that current policy?
Employees Information
Total number of employees
Total number of full time employees
Number of part-time employees (< 30 hrs/week)
Total number of temp/seasonal employees
Number of 1099 (independent contractors) employees
Total number of W2 employees
Do you obtain any employees from or contract with a temp staffing company, employee leasing company or employment agency?
For the next 12 months, what is your estimated payroll expense for yourself, your full-time, part-time, and temporary employees?
General Commercial Liability Section
Do you need Commercial General Liability Insurance Coverage?
Yes
No
LIMITS $
General AGG
Products & Comp. Ops. AGG
Personal & Advertising Inj.
Per Claim or Per Occurance
Each Occurrence
Damage To Rented Premises
Med. Expense
Emp. Benefits
Additional Information
Schedule Of Hazards
Loc#
Haz#
Class Code
Premium Basis
Exposure
Terr
Rate (Prem/OPS)
Rate (Products)
Schedule Of Hazards
Classification/Description of Each
Does Applicant Draw Plans, Designs, Or Specifications For Others?
Yes
No
If yes, please give details:
Do Any Operations Include Blasting Or Utilize Or Store Explosive Material?
Yes
No
If yes, please give details:
Do Any Operations Include Excavation. Tunneling, Underground Work Or Earth Moving?
Yes
No
If yes, please give details:
Do Your Subcontractors Carry Coverages Or Limits Less Than Yours?
Yes
No
If yes, please give details:
Are Subcontractors Allowed To Work Without Providing You With A Certificate Of Insurance?
Yes
No
If yes, please give details:
Does Applicant Lease Equipment to Others with or Without Operators?
Yes
No
If yes, please give details:
Describe The Type Of Work Subcontracted
$ Paid To Sub-contractors
% Of Work Subcontracted:
# Full-time Staff
# Part-time Staff
Products/Completed Operations
Products
Annual Gross Sales
# of Units
Time in Market
Expected Life
Intended Use
Principal Components
Does Applicant Install, Service Or Demonstrate Products
Yes
No
If yes, please give details:
Foreign Products Sold, Distributed, Used As Components?
Yes
No
If yes, please give details:
Research And Development Conducted Or New Products Planned?
Yes
No
If yes, please give details:
Guarantees, Warranties, Hold Harmless Agreements?
Yes
No
If yes, please give details:
Products Related To Aircraft/space Industry?
Yes
No
If yes, please give details:
Products Recalled, Discontinued, Changed?
Yes
No
If yes, please give details:
Products of Others Sold or Repackaged Under Applicant Label?
Yes
No
If yes, please give details:
Products Under Label Of Others?
Yes
No
If yes, please give details:
Vendors Coverage Required?
Yes
No
If yes, please give details:
Does Any Named Insured Sell To Other Named Insureds?
Yes
No
If yes, please give details:
Additional Interest / Certificate Recipient
Additional Insured
Employee As Lessor
Lender's Loss Payable
Lienholder
Loss Payee
Mortgagee
Interest / Certificate Recipient
Name
Address
Rank
Evidence of Certificate?
Reference / Loan #
General Information
Any Medical Facilities Provided Or Medical Professionals Employed Or Contracted?
Yes
No
If yes, please give details:
Any Exposure To Radioactive/Nuclear Materials?
Yes
No
If yes, please give details:
Does Your Company have Past, Present Or Discontinued Operations That Involve Storing, Treating, Discharging, Applying, Disposing, Or Transporting Of Hazardous Material? (E.g. Landfills, Wastes, Fuel Tanks, Etc)
Yes
No
If yes, please give details:
Any Operations Sold, Acquired, Or Discontinued In Last Five (5) Years?
Yes
No
If yes, please give details:
Do You Rent Or Loan Equipment To Others?
Small Tools
Instruction Given for Small Tools?
Large Equipment
Instructions Given for Large Equipment?
Any Watercraft, Docks, Floats Owned, Hired Or Leased?
Yes
No
If yes, please give details:
Any Parking Facilities Owned/rented?
Yes
No
If yes, please give details:
Is A Fee Charged For Parking?
Yes
No
If yes, please give details:
Recreation Facilities Provided?
Yes
No
If yes, please give details:
If There Are Lodging Operations Including Apartments, Answer Questions Below
# Apts
Total Apt Area - Sq Ft
Describe Other Lodging Operations
Are Any of the Following Swimming Pool Amenities on Premises?
Approved Fence
Limited Access
Diving Board
Slide
Above Ground
In Ground
Life Guard
Are Social Events Sponsored?
Yes
No
If yes, please give details:
Are Athletic Teams Sponsored
Yes
No
If yes, please give details:
Any Structural Alterations Contemplated?
Yes
No
If yes, please give details:
Any Demolition Exposure Contemplated?
Yes
No
If yes, please give details:
Has Applicant Been Active In Or Is Currently Active In Joint Ventures?
Yes
No
If yes, please give details:
Do You Lease Employees To Or From Other Employers? If So, Answer Below:
Lease To
Workers Compensation Coverage Carried? (Y/N)
Lease From
Workers Compensation Coverage Carried? (Y/N)
Is There A Labor Interchange With Any Other Business Or Subsidiaries?
Yes
No
If yes, please give details:
Are Day Care Facilities Operated Or Controlled?
Yes
No
If yes, please give details:
Have Any Crimes Occurred Or Been Attempted On Your Premises Within The Last Three (3) Years?
Yes
No
If yes, please give details:
Is There A Formal, Written Safety And Security Policy In Effect?
Yes
No
If yes, please give details:
Does The Businesses' Promotional Literature Make Any Representations About The Safety Or Security Of The Premises?
Yes
No
If yes, please give details:
Hired & Non-Owned Auto Liability Section
Do you need Hired & Non-Owned Auto Liability Coverage?
Yes
No
This specific coverage should be added to the business auto policy.
Does your business currently have a commercial auto policy in force?
Yes
No
What is the range in miles do the company owners or employees travel using hired or non-owned vehicles?
Local (up to 50 miles)
Intermediate (50 to 200 miles)
Long distance (over 200 miles)
What is the use of hired or rented vehicles?
Limited to the occasional use of rental cars for out of town travel
Requirement for a contract
Other
How many employees are required to use their personal auto more than 3 times a week for their job requirements?
1-3
4-10
10 Plus
What is the use of hired or rental vehicles?
Commercial Auto
Do you need commercial auto insurance?
Select
Yes
No
If you would like a personalized Commercial Insurance Quote select yes
Select
Yes
No
Prior Insurance Information
Years with prior carrier?
Years with current policy term?
Years with continuous coverage?
Current Carrier
Current Carrier Expiration Date
MM slash DD slash YYYY
Current Insurance Liability Limits
Primary Liability
Uninsured/Underinsured Motorist Coverage
PIP
Medical Payment
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Total Loss Replacement
Primary Liability Limits
$25 / $50K
$50 / $100K
$100 / $250K
$250 / $500K
CSL $500K
Uninsured/Underinsured Motorist Coverage Limits
$25 / $50K
$50 / $100K
$100 / $250K
$250 / $500K
CSL $500K
PIP Limits
$2,500
$5,000
Medical Payment Limits
$2,500
$5,000
Comprehensive Deductible Limits
$100
$250
$500
$1000
Collision Deductible Limits
$100
$250
$500
$1000
Have you taken defensive driving course(s) in the last 3 years?
Select
Yes
No
Highest Level of Education Completed
High School Diploma
Some College - No Degree
Vocational/Technical Degree
Associate's Degree
Bachelor's Degree
Master's Degree
Phd
Medical Degree
Garaging Address
Description of Operations
Employees/Drivers
Name
DOB
License #
CDL Orig. License Yr
DOH
Vehicles
Year
Make/Model
Type
GVW/Seating
VIN
Radius
Current Value
Commercial Building Information
Do you lease or own the building you are in?
Do you have any property, building, structure or business, personal property contents to insure ?
Yes
No
Commercial Building Construction Type
Fire Resistive
Frame Construction
Joisted Masonry
Masonry Non-Combustible
Modified Fire Resistant
Non Combustible
What is the year built:
Roof Type
Concrete
Flat Roof (Asphalt / Rubber)
Flat Roof (PVC / TPO)
Metal
Shingle (Asphalt / Fiberglass)
Slate / Tile
Poured
Wood Shake
Tile
Unknown / Other
Poured Slate
Year Roof Updated
Year Electrical Updated
Year HVAC Updated
Year Plumbing Updated
Smoke Detectors
None
Wired
Battery
Sprinklered Percentage
Less Than 80%
80 TO 99 %
100%
Distance To Fire Hydrant (Feet)
Miles From Fire Dept
Number of Stories
Security Cameras
Yes
No
Security Guard on Premise When Closed at Night?
Yes
No
Has Bldg Been Certified By a Registered Design Professional
Yes
No
Local Alarm
Smoke Detectors
Burglar
Central Station Monitored Alarm
Fire
Burglar
Is the applicant responsible for Common Area Maintenance?
Yes
No
Is the building undergoing structural renovations currently or are any extensive renovations planned?
Yes
No
Is there a playground on the premises?
Yes
No
Is there a pool on the premises?
Yes
No
Total building coverage needed (If you own building):
Total contents or business property coverage needed:
Standalone building, strip center, or office building?
What is the total square foot for the building you operate in?
How is the property legally titled?
Do you maintain a monitored alarm?
Do you own and operate any other businesses?
Yes
No
Any area leased to others?
Yes
No
Years in Business
Total occupied area?
Total sq. footage open to the public
Loss History
Has your company had any losses or claims during or in the last 5 years?
Yes
No
If Yes:
Date of Occurence
Type, Description
Date of Claim
Amount of Claim
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Name
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