Commercial Insurance Questionnaire
About You
Company Name
Name
Address
City
State
County
Zip
Phone (day)
Phone (night)
Fax
Email
About Your Business
Classification
Sole Proprietor
Partnership
Corporation
LLC Association
Do you currently have Business Owners insurance?
Yes
No
If yes, provide the following:
When does your policy expire?
Who are you currently insured with?
Type of Business
Description of Business Operations
Year business established
Years at current location
Do you own or lease office space?
Own
Lease
Neither
Number of locations
Number of employees
Approxmiate Annual Gross Revenue
Approximate Total Company Payroll
Approximate Amount of Desired Insurance
Approximate Square Footage of Occupancy
Approximate Square Footage of the Entire Building
Have you been named in a lawsuit in the past year?
Yes
No
If yes, briefly explain:
Optional Coverage (check the ones you want)
Business Owners
Workers Compensation
Commercial Auto/Truck
Business Liability
Business Property
Malpractice
Errors and Omissions
Other
Details
When would you like to be contacted?
Morning
Afternoon
Evening
Any Comments/Questions?