COMMERCIAL INSURANCE QUESTIONNAIRE

COMMERCIAL INSURANCE

QUESTIONNAIRE

COMPANY INFORMATION

Company Legal Name:

DBA:

Business Address:

Business Phone: (

Contact Person:

Contact Phone: (

Federal Tax ID#:

SIC:

City:

Business Fax: (

Title:

E-Mail:

)

)

___ C Corp

Type of entity: (Check One)

___ S Corp

Year Established:

Multiple Locations:

Zip:

Yes / No

)

___ Limited Liability Company

___ Partnership

___ Sole Proprietorship

Type of Business:

GENERAL LIABILITY

Complete the information below or forward a copy of your current policy declation page

Gross Revenue:

Current Limits:

General Aggregate:

Personal & Advertising Injury:

Damage to Rented Premises:

Products & Completed Operations:

Medical Expense:

Each Occurance:

Employee Benefit:

PROPERTY

Please include building information for each location, use additional pages if necessary

Current Limits:

Business Income:

Location #1:

Year Built:

Total building square footage:

Business Personal Property:

Address:

# Stories:

Building Improvements:

Wiring Year:

Exposure: What surrounds the building?

Right side:

Alarms/Protection:

Burglar:

Cloud, Minturn Associates

dba: CMA Insurance Services

CA License #0735758

Company:

Computer/Electronic Equipment:

Own

Rent

Construction Type (ie: Steel, Wood, Concrete):

Occupied square footage:

Plumbing Year:

Roofing Year:

Left side:

Rear:

Guard/Wathcman:

SEND COMPLETED FORM TO:

Fax (310) 755-6080 or Email: Service@

Heating Year:

Fire:

Sprinklers:

Phone (310) 316-3662

Fax (310) 755-6080

E-Mail: Service@

COMMERCIAL INSURANCE

QUESTIONNAIRE

UMBRELLA

CURRENT LIMITS

COMMERCIAL COVERAGE HISTORY

Policy Year:

Insurance Carrier:

Policy Number:

Policy Year:

Insurance Carrier:

Policy Number:

Policy Year:

Insurance Carrier:

Policy Number:

VEHICLES

Use additional pages if necessary

CURRENT LIMITS

Liability:

Collission:

VEHICLE #1

Overall Use:

Property Damage:

Compensation:

Make:

Pleasure

VEHICLE #2

Overall Use:

Service

Date of Birth:

Make:

Pleasure

VEHICLE #3

Model:

Retail

Service

Pleasure

DRIVER INFORMATION

Model:

Retail

Service

Name:

Driver's License #:

Year:

Date of Birth:

Make:

VIN#:

Garaging Zip Code:

Mileage to Work:

Name:

# of Vehicles:

# of Drivers:

Year:

Mileage to Work:

Name:

DRIVER INFORMATION

Overall Use:

Model:

Retail

DRIVER INFORMATION

Medical Payments:

Deductible:

VIN#:

Garaging Zip Code:

Driver's License #:

Year:

Mileage to Work:

Date of Birth:

State:

State:

VIN#:

Garaging Zip Code:

Driver's License #:

State:

VEHICLE COVERAGE HISTORY

Policy Year:

Insurance Carrier:

Policy Number:

Policy Year:

Insurance Carrier:

Policy Number:

Policy Year:

Insurance Carrier:

Policy Number:

Cloud, Minturn Associates

dba: CMA Insurance Services

CA License #0735758

SEND COMPLETED FORM TO:

Fax (310) 755-6080 or Email: Service@

Phone (310) 316-3662

Fax (310) 755-6080

E-Mail: Service@

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