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Business Insurance Questionnaire
Business Insurance Questionnaire
Company Name
DBA
Mailing Address
Street Address
Address Line 2
City
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West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Web Address
Contact Name
First
Last
Phone
Alternate Phone
Email
FEIN/TAX ID Number
Entity Type
Description of Operations
Year Business Established
Number Years Experience
Number Full Time Employees
Number of Part Time Employees
Estimated Annual Payroll
Estimate Annual Sales/Revenue
Interest In Any Other Business or Operations
Yes
No
Any Claims or Losses Within the last 5 years (If yes, please describe)
Property Interest
Owner
Tenant
Location Address if different from mailing
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
County
City Limits
Inside
Out
Description of Building
Building Construction
ISO 1 FRAME CONSTRUCTION (Wood walls & Roof, foundation construction does not matter) Masonry Veneer or accents)
ISO 2 JOISTED MASONRY (Free standing Masonry shell with wood floors and joists Flammable roof. (If structure burns masonry walls remain)
ISO 3 Light noncombustible (Structure does not add to fire (fuel) load of building, but does not resist fire well. Light steel construction)
ISO 4 Masonry Noncombustible (Free standing masonry walls with noncombustible floor and roof)
ISO 6 Fire resistive (Walls between fire divisions have 2 hour fire rating, otherwise noncombustible structure)
Year Built (if known)
Sq footage of Building if known
Sq footage you occupy
Building Limit
Contents Limit
Sprinklered
Yes
No
Monitored Alarm
Yes
No
Property Updates
Heating
Yes
No
Wiring
Yes
No
Plumbing
Yes
No
Plumbing Description & Year Updated
Roof Update
Yes
No
Year Roof Updated
Owner/Officer #1
Name
First
Last
Title
%Ownership
Annual Payroll
Owner/Officer #2
Name
First
Last
Title
%Ownership
Annual Payroll
PLEASE INCLUDE THE FOLLOWING WHEN RETURNING THE COMPLETED FORM. These items can be uploaded below. If you do not have the information we can request from the carriers on your behalf. Please ask your account manager for a loss run release letter.
COPIES OF CURRENT POLICIES
Max. file size: 59 MB.
LOSS RUNS/CLAIMS INFORMATION FOR THE PAST 5 YEARS
Max. file size: 59 MB.
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