Business



Business Insurance Questionnaire

( Please fill out this form (type, re-save and email it back if possible) to the best of your knowledge and ability and then we can get on the phone to go over any questions. (You can “TAB” over to get from question to question.)

{ Business Owner Contact Information }

Owner’s Name:      

Business Name:      

Business Address:      

Address 2/Unit #:      

City/State/Zip:      

Phone #:      

Email:      

D/O/Birth:      

{ Current Insurance Information }

Copy of Your Current Policy: Provide if Possible.

Does This Replace an Existing Policy? (Y/N): Yes No

Expiration Date of Existing Policy:      

Current Annual Premium: $     

Current Insurance Carrier:      

Number of Claims in Past 3 Years:      

Any Recent Claims:      

{ Business & Policy Information }

Brief Self-Described Business Description:      

Business Website:      

Business SIC Code [ you can look up if unknown here - ]:      

Business SIC Official Description:      

EIN# or SSN#:      

• Providing your EIN or SSN will get access to more carriers and a more accurate quote.

• Call 206.774.7867 to leave on voicemail if you do not want to write it down.

Contractor License # (if applicable):      

Do you want CGL (Commercial General Liability) or a BOP (Business Owner’s Policy)?: GCL BOP

• Insurance Coverage Amount Requested: $     

Do you need Commercial Auto Coverage: Yes No

• Commercial Auto Insurance Coverage Amount Requested: $     

Physical Building Coverage Limit: $     

Business Personal Property Amount: $     

Desired Effective Date of New Policy:      

Desired Deductible Amount: $     

Continued on the next page…

{ Business Details }

Number of Owners, Partners, etc.:      

Number of Full-Time Employees (Not Owners, Partners, etc.):      

Number of Part-Time Employees (Not Owners, Partners, etc.):      

Do You Sub-Contract Any Work to Others (Y/N): Yes No

If Sub-Contracting, What Percentage of Business is Sub-Contracted to Others:      %

Business Hours (9-5, 20 Hours/Week, etc.):      

Gross Annual Revenue: $     

Gross Annual Payroll (Owners, Partners, etc.): $     

Gross Annual Payroll (Employees): $     

Legal Entity/Status: Proprietorship, Corporation, Partnership, LLC

Number of Years in Business:      

Years of Owner/Management Experience In Industry:      

{ Property Details – REQUIRED FOR ALL QUOTES }

Construction Type (Frame, Brick, etc.):      

Roofing Type (Asphalt, Tar, etc.):      

Year Built:      

Date of Last Update (Roofing, Electrical, Plumbing, HVAC):      

Number of Stories of Building:      

Total Sq. Ft. of Building:      

Total Sq. Ft. of Space Occupied by Business:      

Total Sq. Ft. of Building Vacant:      

If applicable, is there any Vacancy on the ground floor? Yes No

If there is Vacancy on the ground floor, what is the square footage of the vacancy:      

If applicable, what is the square footage of Building Occupied by Condominiums/Apartments:      

Are there any Restaurants on Premises: Yes No

If Restaurants on Premises, How Many:      

Smoke Detectors (Y/N): Yes No

Fire Alarm (Y/N): Yes No

Fire Alarm Type: Local Monitored Direct

Distance From Fire Hydrant:       Feet Miles

Indoor Fire Sprinkler (Y/N): Yes No

If Indoor Fire Sprinkler, What Percentage Is Sprinkled:      

Indoor Fire Sprinkler; Wet or Dry System:      

Fire Extinguisher (Y/N): Yes No

Burglar Alarm (Y/N): Yes No

Burglar Alarm Type: Local Monitored Direct

Is This Space or Building Leased or Owned:      

Is This Business Home-Based:      

If Home-Based, What is The Square Footage of The Occupied Business:      

Do you have Additional Properties or Businesses to insure (Y/N): Yes No

Number of Additional Properties to insure:      

Continued on the next page…

{ Product Details (If Applicable) }

What is the Product that you sell or market:      

What is the intended Use of Product:      

What are the Principal Components of Product:      

Gross Annual Sales from This Product: $     

Number of Products made or sold annually:      

Time in Market:      

Expected Life of Product (one-time-use, days, months, years, etc.):      

Is the Product Imported (Y/N): Yes No

If the Product is Imported, is it Sold or Branded under your Business Name (Y/N): Yes No

What Country is the Product Imported From:      

{ Additional Coverage Interests }

Do you need a Bond: Yes No

If ‘Yes’, What Type of Bond:      

Bond Coverage Amount Requested: $     

Do you need Business Interruption: Yes No

Do you need Errors & Omissions: Yes No

Do you need Errors & Omissions Coverage Amount Requested: $     

Do you need Employment Practices Liability: Yes No

Do you need Directors & Officers Liability: Yes No

Do you need Rental Reimbursement: Yes No

Do you need Loss of Use: Yes No

Do you need Loss of Business: Yes No

Do you need a Commercial Umbrella: Yes No

Do you need Group or Individual Health Insurance: Yes No

{ Additional Comments/Notes (If Applicable) }

     

( Once we get all of this information, we can get you a price indication within 5-10 minutes for contractors and trades (other businesses can take 20-30 minutes) and a firm, bindable, quote within 12-24 hours.

( As a reminder, let us know if you need any other insurance needs. We handle it all; Property & Casualty, Life & Health, LTC, Surety Bonds, Aviation, Boats and more! Everything for your personal life and business ventures... (and you will often get discount for multiple policies with the same carrier)

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