COMMERCIAL GENERAL QUESTIONNAIRE - RJBlock
GENERAL COMMERCIAL QUESTIONNAIRE
Name ___________________________________ Mailing Address____________________________________________________
GENERAL LIABILITY SECTION
Ownership type ____ Individual _____ Partnership _____Corporation _____LLC _____ Non Profit
Email ______________________________ Phone ______________________________ Fax _______________________________
Property/Business Address ________________________ Nature of business __________________________
Annual Revenue ______________________________
Type of insurance needed: _____General Liability _____Business Owners _____ Errors & Omissions ____ Property ____ Worker’s Comp
PROPERTY SECTION
Do you own the building? ________ Square feet of building ________________
Type of construction _____ Frame _____ Brick _____ Masonry Number of stories ___________ Year built__________
Type of Roof (flat rubber asphalt shingle metal slate) Building improvements (What year) Wiring ______ Plumbing_____
Roofing _____Heating _____ Do you need separate boiler insurance? _______ Number of Units_______
Square Feet of Building _________ How many stories ________ If more then 3 is there a fire escape _________
Are there interconnected smoke detectors _________ Is there a sprinkler system ________ burglar alarm_____
Type of Heat (oil or gas) For oil is the tank under ground or above ground _______
Is the building connected to any other buildings _________ Is there a Basement (full finished) ______
What is to the left of the building and what is the distance___________________________________________________________
What is to the right of the building and what is the distance__________________________________________________________
What is in the rear of the building and what is the distance__________________________________________________________
What is in front of the building and what is the distance_____________________________________________________________
Renewal Date ________ Current Premium ______________ Current Insurer _________________________________________
Have you had any claims ______ Date of claim ___/___/_____ Type of claim (slip & fall, fire etc) Is the claim still open _______
WORKERS COMPENSATION SECTION
Classification of employees __________________________________________________________________________________
There can be more than 1 classification for a business. An example would be if a cabinet maker/installation company has a secretary – there could be 3 classes within the same company; 1) Cabinet manufacturing, 2) Cabinet installation and 3) Secretarial.
How many employees _______ Total Payroll _______ Payroll per employee _______Any previous workers comp policies Y / N If so did they lapse or get cancelled _______ (we cannot write another W/C policy on any business until the previous company has been paid up or satisfied)
Current Insurer _________________________ Renewal date _________
Email to rjblock@ or
Fax to RODNEY JACKSON AT THE PANGBORN AGENCY 908-668-8140
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