• Login

Quote Form

 

BUSINESS PACKAGE QUESTIONNAIRE

DATE:

LEGAL NAME:

DBA:

MAILING ADDRESS:

PHYSICAL ADDRESS:

WEBSITE:

CONTACT NAME:

PHONE:

Email:

ENTITY TYPE (INDIVIDUAL, CORP, PARTNERSHIP, ETC.):

YEARS IN BUSINESS:

IF NEW VENTURE, YEARS OF EXPERIENCE IN FIELD:

DESCRIPTION OF OPERATIONS:

COVERAGES:

COMMERCIAL GENERAL LIABILITY LIMITS:

ESTIMATED ANNUAL GROSS SALES/RECEIPTS:

ESTIMATED ANNUAL GROSS PAYROLL:

ESTIMATED ANNUAL GROSS LIQUOR SALES (IF APPLICABLE):

COMMERCIAL PROPERTY LIMITS:

BUILDING:

BUSINESS PERSONAL PROPERTY:

BUSINESS INCOME:

TENANTS IMPROVEMENTS:

YEAR BUILT:

AREA (SQ.FT.):

CONSTRUCTION TYPE (FRAME, MASONRY…):

#OF STORIES:

LAST UPDATES PLUMBING, ELECTRICAL, ROOF (YR):

AUTOMATIC FIRE SPRINKLERS (Y/N):

CENTRAL STATION BURGLAR ALARM (Y/N):

CENTRAL STATION FIRE ALARM (Y/N):

ANY VACANCIES (%):

CURRENT INSURANCE INFO (OR ATTACH DECLARATION PAGE):

CARRIER NAME:

# OF YEARS OF PRIOR INSURANCE:

ANY CLAIMS IN THE PAST 4 YEARS:

CURRENT POLICY EXPIRATION DATE:

TARGET PREMIUM:


WORKERS/COMPENSATION

PAYROLL BREAKDOWN PER CLASS CODE

(ESTIMATED ANNUAL GROSS PAYROLL. DO NOT INCLUDE THE OFFICERS’ PAYROLL)

A. Class:

B. Class:

C. Class:

FEIN #

EXCLUDED OFFICERS’ NAMES:

CURRENT INSURANCE INFO (OR ATTACH DECLARATION PAGE):

# OF YEARS OF PRIOR INSURANCE:

ANY CLAIMS IN THE PAST 4 YEARS:

CURRENT POLICY EXPIRATION DATE:

TARGET PREMIUM:

COMMERCIAL AUTO

VEHICLES:

1) YEAR

MAKE/MODEL

GVW

VALUE

2) YEAR

MAKE/MODEL

GVW

VALUE

3) YEAR

MAKE/MODEL

GVW

VALUE

4) YEAR

MAKE/MODEL

GVW

VALUE

DRIVERS:

1) NAME

DOB

DL

2) NAME

DOB

DL

3) NAME

DOB

DL

4) NAME

DOB

DL

COMMERCIAL AUTO COVERAGES:

LIABILITY LIMITS:

UNINSURED MOTORIST:

MEDICAL PAYMENTS:

COMP/COLL DEDUCTIBLES:

CURRENT INSURANCE INFO (OR ATTACH DECLARATION PAGE):

# OF YEARS OF PRIOR INSURANCE:

ANY CLAIMS IN THE PAST 4 YEARS:

CURRENT POLICY EXPIRATION DATE:

TARGET PREMIUM:

BOND

WHO’S REQUIRING IT?

BOND LIMIT:

CURRENT INSURANCE COMPANY NAME:

CURRENT BOND EXPIRATION DATE: