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 "C" Corporation"S" CorporationPartnershipIndividualLLCLLP 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 Primary ResidenceSecondary ResidenceRented to Others Primary ResidenceSecondary ResidenceRented to Others Year Updated - HVAC Year Updated - Plumbing Fire Extinguishers NoYes NoYes Smoke Detectors BatteryWired BatteryWired Alarm LocalCentral LocalCentral Protection Class % of Building Sprinklered Contents Value Business Income Value Period of Restoration 1/31/41/61/12Actual 1/31/41/61/12Actual Building Possession OwnedLeased OwnedLeased PTY Deduct. Requested 5001,0005,000 5001,0005,000 Mortgagee* NoYes NoYes Additional Insureds* NoYes NoYes *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* NoYes NoYes Sub-Contractors Used NoYes NoYes Cost of Sub-Contractors Sub. Agreements Used** NoYes NoYes Sub. Certs. Obtained NoYes NoYes 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 CommercialServiceRetail DeliveryPersonal CommercialServiceRetail DeliveryPersonal CommercialServiceRetail DeliveryPersonal CommercialServiceRetail DeliveryPersonal Collision NoYes NoYes NoYes NoYes - Deductible Comprehensive NoYes NoYes NoYes NoYes - Deductible Radius of Use 50100200 50100200 50100200 50100200 Garaging Zip Code Loss Payee NoYes NoYes NoYes NoYes 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. spacer 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 $0$5,000$10,000$20,000 Notes Additional Coverages Requested - Supplementals Required Aircraft Liability NoYes Cyber Liability Insurance NoYes Directors & Officers Liability NoYes Earthquake Coverage NoYes Employment Practices Liability - Stand Alone NoYes Flood Coverage NoYes Garage Liability/GarageKeepers NoYes Liquor Liability NoYes Marine Liability NoYes Pollution NoYes Professional Liability NoYes Current/Prior Insurance Information 2013201220112010 Carrier Expiration Date Property Premium Liability Premium Auto Premium WC Premium Umbrella Premium
