Business Insurance Questionnaire

Name:*

DBA (if applicable):

Mailing Address:

City:

State:

Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont US Virgin Islands Washington Wisconsin West Virginia Wyoming

Zip Code:

Contact Person:

Phone Number:

Fax Number:

Email Address:*

Website:

Nature of Business:

Year Started:

Type of Business:

Select type of Business Individual Partnership Corporation

Any Bankruptcies in last Five Years?

Yes    No

Prior Coverage?

Yes    No

If Yes, Please Provide:

With Whom:

When Coverage Ended:

(The insurance carrier, may request loss runs from previous/current carrier or a no loss statement)

Any Claims/Losses Last Three Years?

Yes    No

If Yes, Please provide details:

Location Address:

City:

State:

Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont US Virgin Islands Washington Wisconsin West Virginia Wyoming

Zip Code:

Location Address:

City:

State:

Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont US Virgin Islands Washington Wisconsin West Virginia Wyoming

Zip Code:

Location Address:

City:

State:

Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont US Virgin Islands Washington Wisconsin West Virginia Wyoming

Zip Code:

If Lessors Risk, please advise occupancy:

Also, if lessors risk we would recommend that the lessor have the tenant carry their own insurance for their business and name the lessor as additional insured.
(It may also likely be a requirement of the insurance carrier – and a certificate of insurance may be requested)

Type of Coverage Seeking:

Select the Type of Coverage you are Seeking Liability Property Both Liability and Property Loss of Income/Rent/Extra Expense

Liability = Trip/Fall etc.
Property = Building, Business Personal Property Loss of Income/Rent/Extra Expense= Written under many different forms.

Standard Liability Coverages:
1,000,000 General Aggregate
1,000,000 Products/Complete Ops Aggregate
1,000,000 Personal & Advertising Injury
1,000,000 Occurrence
50,000 Damage to Rented Premises
2,000 Medical Payments

Square Footage:

Annual Receipts:

Annual Payroll:

Acres (if vacant land):

The above is by location.  So if there are additional locations, please list separately in box below.

Any Additional Insured Endorsements Required:

If Yes, please provide:

Yes    No

Name:

Address:

If Building Coverage is desired,
Please complete the following:

Year Built:

Type of Construction:

Select Type of Construction Steel Frame Masonry

Protection Class:

Number of Stories:

Alarm:

  Yes   No

If Yes, is it a Central Station?

  Yes   No

If Yes, who is it monitored by?

Exposure to Right:

Exposure to Left:

Exposure to Front:

Exposure to Back:

Updates

Roof:

Electric:

Plumbing:

Heating:

Distance to Fire Hydrant:

Distance to Fire Station:

If BPP (Business Personal Property) coverage is desired, please advise:

Amount:

If Loss of Rent/Income is desired, please advise:

Amount:

Exposures / Classifications that would be subject to a supplemental application:

• Apartments
• Auto Dealers
• Auto Repair Shops
• Beauty Parlor / Barber Shop
• Bowling Alley
• Contractors
• Daycares
• Fitness Center / Gym
• Hotel / Motel
• Restaurants
• Tanning Salon
• Taverns
• Trucking
• Vacant Buildings

* Indicates required field