Business Insurance Questionnaire Business Insurance Questionnaire 1Contact2Business Details3Ownership4Liability5Workers Compensation6Vehicles7Drivers8Property9Bonds10Other Business Information Business Insurance Tell us about business. Business Name(Required) Primary Contact Name(Required) First Last Primary Contact Phone(Required)Primary Contact Email(Required) Where can we send proposalsBusiness Website Underwriters will often google business, please provide you website for reviewBusiness Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Questionnaire ID Business Details Tell Us About Your Business Details Tell us about business Details Type of Work of Business(Required) Accounting, Restaurant, Consulting, Carpentry, etc.Type of Insurance Needed(Required) Liability Workers Compensation Vehicle Coverage Property Coverage Bond Other/Not Listed Estimated Annual Gross Sales(Required)Estimated sales for next 12 monthsEstimated Annual Payroll(Required)Estimated payroll for next 12 months (Not including Owner)Estimated Subcontracted Costs(Required)Estimated to be paid to subcontractors (not employees) for next 12 months (Not including Owner)Federal Tax ID Number Should be 10 digit #, usually in this format -##-########Entity Type(Required)LLCCorporationSole ProprietorshipIndividualNon-ProfitHow is your business set up, LLC, Inc., Sole Proprietorship, etc.How did you hear about us Referral Web Search Email Our Webpage Other # of Owners(Required) 1 2 3 4 5 6 7 8 9 10 or more # of Full Time Employees(Required) 0 1 2 3 4 5 6 7 8 9 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 or greater # of Part Time Employees(Required) 0 1 2 3 4 5 6 7 8 9 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 or greater # of Locations(Required) 1 2 3 4 5 or More Ownership Owners Tell us about Ownership. Primary OwnerPrimary Owner Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Social Security # Drivers License # Need if Vehicle insurance is requestedEducation High School Graduate Some College College Graduate Bachelors Masters PHD MD Used with underwriting for best pricingGender Male Female n/a Years Related Experience(Required)0, None11 Months or less1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years or moreOwnership Percentage(Required) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% or less Owner 22nd Owner Name First Last 2nd Owner Date of Birth MM slash DD slash YYYY 2nd Owner Social Security # 2nd Owner Drivers License # Need if Vehicle insurance is requested2nd Owner Education High School Graduate Some College College Graduate Bachelors Masters PHD MD Used with underwriting for best pricing2nd Owner Gender Male Female n/a 2nd Owner Years Related Experience(Required)0, None11 Months or less1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years or more2nd Ownership Percentage(Required) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% or less Owner 33rd Owner Name First Last 3rd Owner Date of Birth MM slash DD slash YYYY 3rd Owner Social Security # 3rd Owner Drivers License # Need if Vehicle insurance is requested3rd Owner Education High School Graduate Some College College Graduate Bachelors Masters PHD MD Used with underwriting for best pricing3rd Owner Gender Male Female n/a 3rd Owner Years Related Experience(Required)0, None11 Months or less1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years or more3rd Ownership Percentage(Required) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% or less Owner 44th Owner Name First Last 4th Owner Date of Birth MM slash DD slash YYYY 4th Owner Social Security # 4th Owner Drivers License # Need if Vehicle insurance is requested4th Owner Education High School Graduate Some College College Graduate Bachelors Masters PHD MD Used with underwriting for best pricing4th Owner Gender Male Female n/a 4th Owner Years Related Experience(Required)0, None11 Months or less1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years or more4th Ownership Percentage(Required) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% or less Liability Coverage Liability Insurance Tell us what type of liability protection you need Liability Limits Needed $1,000,000 $2,000,000 $3,000,000 $500,000 $250,000 Other Location of Work Office, Client's Home, Clients Business, etc.Explanation of WorkWhat type of work will be complete, accounting, roofing, home health care, etc.Type of Liability Coverage General Liability Professional Liability Occurrence Coverage Claims Made Coverage - Professional Liability Workers Compensation Workers Compensation Workers Compensation is required in most states for employees, if you have employees to different type of work please separate into different classes and jobs. All the payroll amounts are to be annual (Yearly) Limits of Workers Compensation $100,000/$500,000/$100,000 - Standard $1,000,000 - Extra Other How Many different Classes or Type of Jobs 1 2 3 4 5 or more Clerical, Sales, Carpenter, etc. Different type of work is charged differently1st Class or Job1st Class or Type of Work Description Customer Service Rep, Carpenter, Sales Person, etc.1st Number of Employees Doing this job 0 1 2 3 4 5 or More 1st Estimated Total Annual Payroll for this jobAll employees doing this type of work will be paid, i.e. 3 employees earning $50,000 a year, $150,000 total1st Any notes or remarks for this Job2nd Class or Job2nd Class or Type of Work Description Customer Service Rep, Carpenter, Sales Person, etc.2nd Number of Employees Doing this job 0 1 2 3 4 5 or More 2nd Estimated Total Annual Payroll for this jobAll employees doing this type of work will be paid, i.e. 3 employees earning $50,000 a year, $150,000 total2nd Any notes or remarks for this Job3rd Class or Job3rd Class or Type of Work Description Customer Service Rep, Carpenter, Sales Person, etc.3rd Number of Employees Doing this job 0 1 2 3 4 5 or More 3rd Estimated Total Annual Payroll for this jobAll employees doing this type of work will be paid, i.e. 3 employees earning $50,000 a year, $150,000 total3rd Any notes or remarks for this Job4th Class or Job4th Class or Type of Work Description Customer Service Rep, Carpenter, Sales Person, etc.4th Number of Employees Doing this job 0 1 2 3 4 5 or More 4th Estimated Total Annual Payroll for this jobAll employees doing this type of work will be paid, i.e. 3 employees earning $50,000 a year, $150,000 total4th Any notes or remarks for this Job5th Class or Job5th Class or Type of Work Description Customer Service Rep, Carpenter, Sales Person, etc.5th Number of Employees Doing this job 0 1 2 3 4 5 or More 5th Estimated Total Annual Payroll for this jobAll employees doing this type of work will be paid, i.e. 3 employees earning $50,000 a year, $150,000 total5th Any notes or remarks for this Job Vehicle Coverage Vehicle Insurance Vehicle insurance can include liability and physical damage coverage. We use many different Carriers. Liability Limit Desired(Required) $1,000,000 $2,000,000 $500,000 $250,000 $100,000/$300,000/$100,000 Other # of Vehicles to Insure(Required) 1 2 3 4 5 or More # of Drivers to Insure(Required) 1 2 3 4 5 or More Vehicle 1Vehicle 1 Year(Required) Vehicle 1 Make(Required) Vehicle 1 Model(Required) Vehicle 1 VIN Vehicle 1 Coverage Desired Liability Comprehensive Coverage (Non-Collision) Collision Coverage Rental Reimbursement Towing $0 Glass Deductible Vehicle 1 Primary Driver Vehicle 1 Usage Pleasure Use Business Use Commute to Work Farm Use Retail Use Vehicle 1 Notes or RemarksVehicle 2Vehicle 2 Year(Required) Vehicle 2 Make(Required) Vehicle 2 Model(Required) Vehicle 2 VIN Vehicle 2 Coverage Desired Liability Comprehensive Coverage (Non-Collision) Collision Coverage Rental Reimbursement Towing $0 Glass Deductible Vehicle 2 Primary Driver Vehicle 2 Usage Pleasure Use Business Use Commute to Work Farm Use Retail Use Vehicle 2 Notes or RemarksVehicle 3Vehicle 3 Year(Required) Vehicle 3 Make(Required) Vehicle 3 Model(Required) Vehicle 3 VIN Vehicle 3 Coverage Desired Liability Comprehensive Coverage (Non-Collision) Collision Coverage Rental Reimbursement Towing $0 Glass Deductible Vehicle 3 Primary Driver Vehicle 3 Usage Pleasure Use Business Use Commute to Work Farm Use Retail Use Vehicle 3 Notes or RemarksVehicle 4Vehicle 4 Year(Required) Vehicle 4 Make(Required) Vehicle 4 Model(Required) Vehicle 4 VIN Vehicle 4 Coverage Desired Liability Comprehensive Coverage (Non-Collision) Collision Coverage Rental Reimbursement Towing $0 Glass Deductible Vehicle 4 Primary Driver Vehicle 4 Usage Pleasure Use Business Use Commute to Work Farm Use Retail Use Vehicle 4 Notes or RemarksVehicle 5Vehicle 5 - Year Make Model VIN Usage - List more vehicles here. Drivers Drivers Drivers Driver Details All Drivers are listed There are no Accidents or Vehicle Claims (3 Years) All Vehicles are garaged at business address Vehicle are garaged at home addresses Driver 1Driver 1 Name(Required) First Last Driver 1 Date of Birth(Required) MM slash DD slash YYYY Driver 1 Gender(Required) Male Female n/a Driver 1 Martial Status(Required) Single Married Widowed Divorced Separated n/a Driver 1 Social Security # Driver 1 Drivers License State(Required) Driver 1 Drivers License #(Required) Driver 1 Primary Vehicle Driven Driver 1 All Tickets and Accidents in last 5 yearsInclude Date, description, amount paid, State none if no tickets or accidents in 5 years.Driver 2Driver 2 Name(Required) First Last Driver 2 Date of Birth(Required) MM slash DD slash YYYY Driver 2 Gender(Required) Male Female n/a Driver 2 Martial Status(Required) Single Married Widowed Divorced Separated n/a Driver 2 Social Security # Driver 2 Drivers License State(Required) Driver 2 Drivers License #(Required) Driver 2 Primary Vehicle Driven Driver 2 All Tickets and Accidents in last 5 yearsInclude Date, description, amount paid, State none if no tickets or accidents in 5 years.Driver 3 or MoreDrivers - List Names, DOBs, Drivers License #s, Vehicle Driven, Tickets & Accidents Property Coverage Property Coverage Property Premises Status Building Owner Tenant Leasee Home Office Location 1# of Buildings 1 Building 2 Buildings 3 Buildings Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Year Built Construction Type Frame Concrete Brick Exterior Material Wood Siding Vinyl Siding Brick Concrete Metal Square Footage of business Number of Stories 1 2 3 4 5 or More Building Coverage Amount Desired Contents Coverage Amount Desired Age of Wiring (Update Date) Age of Roof(Update Date) Age of Plumbing (Update Date) Age of Heating (Update Date) Safety Features Local Fire Alarm Central Fire Alarm (Calls Fire Department) Local Burglar Alarm Central Fire Alarm (Calls Fire Department) Sprinklers Guards Risks Animals Swimming Pool Business Activity Restaurant Auto Repair Habitational (Renters) Bonds Bonds Bond How Many bonds are needed(Required) 1 Bond 2 Bonds 3 or More Bonds Bond 1Bond 1 Description(Required) Bond 1 Penalty Amount Bond 1 Obligee (Who is requesting Bond) Bond 2Bond 2 Description(Required) Bond 2 Penalty Amount Bond 2 Obligee (Who is requesting Bond) Bond 3 or MoreList bonds needed with description, penalty amount, and obigee (requestor) Other Insurance Needs Other Insurance Other Insurance List all other insurance needs, description, amount needed etc. Δ
