Group Medical Cencus
* = Required
Contact Information
Name*
Phone*
Email*
General Information
Corporation Name
Address
Effective Date
First NameLast NameFT/PTSex M/FZip CodeDate of BirthSmoker Yes/NoSpouse Date of BirthSmoker Yes/NoChild - Date of Birth / SexChild - Date of Birth / SexChild - Date of Birth / SexWaive Coverage / Reason

 

Automobile Change Request
* = Required
Contact Information
Name*
Phone*
Email*
General Information
Named Insured
Date
Effective Date of Change
Vehicle
Action
Year
Make
Model
VIN #
Comprehensive
Deductible
Collision
Deductible
Action
Type
Name
Address
Driver
Action
Name
Date of Birth
License Number
State
Signed
Date

 

Auto I.D. Card Request
* = Required
Contact Information
Name*
Phone*
Email*
General Information
Named Insured
Date
Effective Date of Change
Vehicle Information
Year
Make
Model
VIN #

 

Certificate of Insurance Request
* = Required
Contact Information
Name*
Phone*
Email*
General Information
Named Insured
Date
Effective Date of Change
Certificate Holder
Name
Address
Fax #
Certificate Holder Is
Special Requests
*Please forward by email any specific requirements received from the party requesting the certificate.

 

General Liability Change Request
* = Required
Contact Information
Name*
Phone*
Email*
General Information
Named Insured
Date
Effective Date of Change
Action
Payroll Amount
Sub-Contractor Costs
Gross Annual Sales
Action
Type
Name
Address
Loan Number
Signed
Date

 

Inland Marine Change Request
* = Required
Contact Information
Name*
Phone*
Email*
General Information
Named Insured
Date
Effective Date of Change
Action
Year
Make
Model
Serial #
Cost New
Year
Make
Model
Serial #
Cost New
Action
Type
Name
Address
Signed
Date

 

Property Change Request
* = Required
Contact Information
Name*
Phone*
Email*
General Information
Named Insured
Date
Effective Date of Change
Action
Location Address
Building Value
Contents Value
Business Income
Deductible
If adding a location, please provide the following
Year Built
Square Footage
Construction
% Occupied
% Sprinklered
Alarm Type
Updates
Roof
HVAC
Plumbing
Electric
Action
Type
Name
Address
Signed
Date

 

Life Insurance Questionnaire
* = Required
Contact Information
Name*
Phone*
Email*
General Information
Name
Date of Birth
Address
Phone Number
Fax Number
Type of insurance Requesting
Amount of insurance requesting
Sex
Height
Weight
Are you currently a tobacco user?
Type
Amount per Day
Have you used tobacco in the past?
How long has it been since you used a tobacco product
Please list any known health problems
Please list any prescribed medications you are currently taking
Do you want any child riders added
Name
Date of Birth
Name
Date of Birth
Signed
Date

 

Automobile Insurance Questionnaire
* = Required
Contact Information
Name*
Phone*
Email*
General Information
Location Address
County of Residence
Years at location
Previous Address (If less than 6 Months)
Phone #
Mobile Phone #
Date of Birth
Social Security #
Employer
Occupation
Co-Applicant Name
Date of Birth
Social Security #
Has any coverage been canceled, declined or non-renewed within the last 3 years?
Automobile
Vehicle Information
YearMakeModelVIN #Cost New
Loss Payee/Additional Insured Information
Name of Institution
Address
Loan #
Vehicle
Name of Institution
Address
Loan #
Vehicle
Name of Institution
Address
Loan #
Vehicle
Name of Institution
Address
Loan #
Vehicle
Driver Information
NameDate of BirthLicense NumberState
Additional Information
Are there any licensed drivers in the household that are not listed above?
If Yes: Explain
Any driver training courses taken?
If Yes: Explain
Loss History
Date of LossDescriptionAmount Paid
Prior Carrier
YearInsurance CompanyAnnual Premium
PLEASE PROVIDE COPY OF CURRENT AUTO POLICY FOR LIMITS OF INSURANCE
Notes

 

Home Insurance Questionnaire
* = Required
Contact Information
Name*
Phone*
Email*
General Information
Location Address
County of Residence
Years at location
Previous Address (If less than 6 Months)
Phone #
Mobile Phone #
Date of Birth
Social Security #
Employer
Occupation
Co-Applicant Name
Date of Birth
Social Security #
Has any coverage been canceled, declined or non-renewed within the last 3 years?
Homeowners
Home Information
Is this a new purchase?
Month/Year Purchased
Current Insured Value (Replacement Cost)
Liability Limit Requested
Deductible
Home Usage
Year Built
Square Footage
# of Stories
Construction Type
Style
Heat Type
Alternate Heat Source
Type (If yes)
Fireplace(s) #
Fireplace Type
Roof Material
Roof Type
Protection Devices
Smoke Alarm
Protection Devices
Burglar Alarm
Sprinkler System
Deadbolt Locks
Circuit Breakers
Fire Extinguishers
Updates:
Wiring
Plumbing
Heating
Roof
Basement
If Yes: Finished
Square Footage
Swimming Pool
Fenced(If Yes)
Diving Board (If Yes)
Type (If yes)
Garage
Type (If yes)
# of Cars
Distance to Fire Department
Distance to Hydrant
Full Bathrooms (# by Type)
Designer
Standard
Builder's Grade
Half Bathrooms (# by Type)
Designer
Standard
Builder's Grade
Kitchen (# by Type)
Designer
Standard
Builder's Grade
Other Structures on Property
Type (If yes)
Additional Information
Any farming or other business conducted on premises?
Type (If yes)
Any Residence Employees?
If Yes: How Many
FT
PT
Type
Any other residence owned, occupied or rented?
Any Pets?
If yes: Type (If Dog, include Breed)
Is property located on more than 5 acres?
If yes: How many
Does applicant own any recreational vehicles?
If yes: How many
Type(s)
Is building undergoing any renovation or reconstruction?
If yes: Describe
Is there a trampoline?
Is the property located in a Flood Zone?
Mortgage Information
1st Mortgagee:
Name of Mortgage Company
Address
Loan #
Is mortgage escrowed?
2nd Mortgagee:
Name of Mortgage Company
Address
Loan #
Is mortgage escrowed?
Valuable Items/Collections
Jewelry Total Value
Furs Total Value
Fine Arts Total Value
Firearms Total Value
Silverware Total Value
Other (Describe)
Description of Other
Loss History
Date of LossDescriptionAmount Paid
Prior Carrier
YearInsurance CompanyAnnual Premium
Notes

 

Commercial Lines Questionnaire
* = Required
Contact Information
Name*
Phone*
Email*
Please provide all information below so that a quotation may be obtained.
General Information
Name Insured
Address of Business
(Location #1)
Mailing Address
(If different than physical address)
Phone Number
Fax Number
Contact Person
Email Address
Website
Business Information
Year Business Started
# Of Years Experience
# Of Full Time Employees
# Of Part Time Employees
Federal ID #
Type of Business
Complete Description of Business Operations
Property
 Location #1Location #2
Building Value
Square Footage
% Occupied by Insured
# of Stories
Construction of Building
Year Built
Year Updated - Roof
Year Updated - Electric
Year Updated - HVAC
Year Updated - Plumbing
Fire Extinguishers
Smoke Detectors
Alarm
Protection Class
% of Building Sprinklered
Contents Value
Business Income Value
Period of Restoration
Building Possession
PTY Deduct. Requested
Mortgagee*
Additional Insureds*
*Please complete information below
Location #2 Address
Mortgagee/Additional Insureds:
Name
Address
Interest
Name
Address
Interest
General Liability
 Location #1Location #2
Occurrence Limit
Aggregate Limit
Fire Legal Liability Limit
Gross Annual Sales
Payroll
Payroll Classification
Additional Insureds*
Sub-Contractors Used
Cost of Sub-Contractors
Sub. Agreements Used**
Sub. Certs. Obtained
Limits Required for Subs
Any Vacant Land - Acres
Any Leased BLDGs. - #
*Please complete information below
**Please obtain copy of sub-contractor agreement
Additional Insureds:
Name
Address
Interest
Name
Address
Interest
Crime
 Location #1Location #2
Accounts Receivable
Employee Dishonesty
Monies & Securities - In
Monies & Securities - Out
Valuable Papers/Records
Forgery & Alterations
Automobile
Policy Level Coverage
Limit of Liability
Hired/Non-Owned Liability
Hired Physical Damage
Cost of Hire
Driver other Car
# of People - D.O.C.
Names of D.O.C. Drivers
 Vehicle #1Vehicle #2Vehicle #3Vehicle #4
Year
Make
Model
Vin #
Cost New
GVW
Use
Collision
- Deductible
Comprehensive
- Deductible
Radius of Use
Garaging Zip Code
Loss Payee
Loss Payees
Name
Address
Vehicle
Name
Address
Vehicle
Driver Schedule
 Driver #1Driver #2Driver #3Driver #4
Name
State Licensed
Date of Birth
License #
Inland Marine
 #1#2#3#4
Year
Make
Model
Serial #
Actual Cash Value
Deductible
Installation Floater:
Amount of Coverage Desired
Blanket Value
Unscheduled Equipment Value
Maximum Value Per Item - Unscheduled
Computer Equipment
 HardwareSoftware
Description
Value
Boiler & Machinery
 Location #1Location #2
Building Limit
Contents Limit
Machinery/Equipment Limit
Deductible
Workers' Compensation
 Class CodeClass CodeClass CodeClass Code
Class Code
Class Description
Payroll
# of Full Time Emp.
# of Part Time Emp.
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Corporate Officers
 PresidentV. PresidentSecretaryTreasurer
Name
Date of Birth
Social Security #
% of Ownership
Included/Excluded
Annual Salary
Officers Duties
Umbrella
Limit of Liability Requested
Self-Insured Retention
Notes
Additional Coverages Requested - Supplementals Required
Aircraft Liability
Cyber Liability Insurance
Directors & Officers Liability
Earthquake Coverage
Employment Practices Liability - Stand Alone
Flood Coverage
Garage Liability/GarageKeepers
Liquor Liability
Marine Liability
Pollution
Professional Liability
Current/Prior Insurance Information
 2013201220112010
Carrier
Expiration Date
Property Premium
Liability Premium
Auto Premium
WC Premium
Umbrella Premium