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Business Insurance Questionnaire

To provide a quote, we need to gather some information about you and your business. Get started using the form below.

Step 1 of 7

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This field is for validation purposes and should be left unchanged.

Owner Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Business Information

Name of Business(Required)

Website

Business Address(Required)

Street Address Address Line 2 City State ZIP Code

Is your mailing address different from your business address?(Required)

Yes

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Industry

Description of Business

Type of Ownership(Required)

Sole Proprietor

Partnership (LP/LLP)

LLC

Corporation (C or S)

Nonprofit (NPO)

Other

Do you have a Federal ID #?(Required)

Yes

Federal ID #(Required)

Number of years in business

Number of years of experience

Estimated Annual Sales(Required)

Current or previous year

Estimated Annual Payroll(Required)

Current or previous year

Do you have employees?(Required)

Yes

Number of full-time employees(Required)

Number of part-time employees(Required)

Do you utilize sub-contractors?(Required)

Yes

Estimated annual expense of sub-contractors(Required)

Current or previous year

Do you require them to carry General Liability and Workers Compensation?

Yes

Insurance Information

What type(s) of insurance are you looking for?(Required)

General Liability

Property

Automobile

Workers' Compensation

Contractors Equipment

Have you had any prior insurance policies for this business?(Required)

Yes

Who was your prior insurance carrier?(Required)

Have you had any prior losses?(Required)

Yes

Please list any prior losses(Required)

Provide details including dates. Click the plus sign to the right to add a new line.

How much coverage is needed for your contractors equipment?(Required)

Property Information

Year Built

Is the property owned or leased?

Owned

Leased

Mortgagee or Additional Interest

Total Sq. Ft. of Building

Sq. Ft. You Occupy

# of Stories

Basement

Yes

Building's ISO Construction Type

Frame

Joisted Masonry

Noncombustible

Masonry Noncombustible

Modified Fire Resistive

Fire Resistive

Does the building have an alarm?

Yes

Alarm Type(s)

Select all that apply

Local

Central Station

UL Central Station

Monitored Fire

Sprinkler Monitoring

Other

Other Alarm Type

Year Updated

Electrical

Roof

Plumbing

HVAC

Insurance Info

Limit on Building

Limit of Contents

Deductible

Tools / Equipment Limit

Please upload an itemized list.

Accepted file types: jpg, png, heic, pdf, doc, docx, Max. file size: 10 MB.

Auto Coverage

Collision Deductible

Comprehensive Deductible

How many vehicles to insure?(Required)

How many drivers?(Required)

Do you have a personal auto policy?(Required)

Yes

Do you rent vehicles?(Required)

Yes

Are any of the vehicles personally titled?(Required)

Yes

Vehicle 1 Information

Year(Required)

Make(Required)

Model(Required)

VIN(Required)

Cost New

Loss Payee

Vehicle 2 Information

Year(Required)

Make(Required)

Model(Required)

VIN(Required)

Cost New

Loss Payee

Vehicle 3 Information

Year(Required)

Make(Required)

Model(Required)

VIN(Required)

Cost New

Loss Payee

Vehicle 4 Information

Year(Required)

Make(Required)

Model(Required)

VIN(Required)

Cost New

Loss Payee

Vehicle 5 Information

Year(Required)

Make(Required)

Model(Required)

VIN(Required)

Cost New

Loss Payee

Please upload a list of your vehicles that includes (Year, Make, Model, VIN, Cost New, Loss Payee if applicable)

Spreadsheet preferred, can be a picture of handwritten list.

Max. file size: 10 MB.

Driver 1 Information

Driver Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Driver's License Number(Required)

Enter as it appears on the license (letters and numbers).

Driver 2 Information

Driver Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Driver's License Number(Required)

Enter as it appears on the license (letters and numbers).

Driver 3 Information

Driver Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Driver's License Number(Required)

Enter as it appears on the license (letters and numbers).

Driver 4 Information

Driver Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Driver's License Number(Required)

Enter as it appears on the license (letters and numbers).

Driver 5 Information

Driver Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Driver's License Number(Required)

Enter as it appears on the license (letters and numbers).

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