What is your first name? *
What is your last name? *
What is your phone number? *
What is your email? *
What is your company's name? *
Please provide a brief description of your business operations. *
What is your role?
Please provide a description of your role.
What is the primary mailing address for the company? *
What is the entity type of your company?
What is the entity type for the company?
Please enter your Federal Identification Number (FEIN)? *
Is there more than one owner?
Please list the members/owners/officers along with their respective ownership interests:
What year was the company established? (YYYY)
What is your website address?
What date would you like coverage to begin? *
MM slash DD slash YYYY
Excluding computers and media equipment, what is the approximate value of the business personal property owned by the company? (Office furniture, copiers, inventory, tools, etc...)
What is the value of the computers & media equipment owned by the company?
What are the company's annual gross receipts?
How many locations does the company have? *
Location #1
Do you own or lease this location? *
What is the value of the improvements and betterments made to the leased location(s)?
What is the legal name of the owner of the building?*
Check this box if this location's address is the same as your primary address entered above.
What is the address of the location for which you are providing information?*
Construction
Please select the building's construction type.
Please select the term that best describes the condition of the building.
Please select the term that best describes the quality of the building.
What construction material was used for the walls?
What year was the electrical wiring last updated? (YYYY)
Was the electrical wiring update partial or complete?
What year was the plumbing system last updated? (YYYY)
Was the plumbing system update partial or complete?
What year was the heating system last updated? (YYYY)
Was the heating system update partial or complete?
What type of heating system does the building have?
What year was the cooling system last updated? (YYYY)
Was the cooling system update partial or complete?
What type of cooling system does the building have?
What type of fuel does the heating/AC system utilize?
What year was the roof last updated? (YYYY)
Was the roof update partial or complete?
What is this building's roof type?
Please enter the building's roof type.
Does the building have a basement?
Does the building have an attic/penthouse?
What year was the building built? (YYYY)
Has the building been gut renovated since its was built?
What year was the building renovated? (YYYY)
What is the floor height? (In feet)
How many floors/stories does the building have?
What is the total square footage of the building?
What is the square footage of the space your company occupies in this building?
What is the value of the building?
What is the replacement cost of the building?
What is the value of the contents within the building?
Occupancy Classification
What is the occupancy classification of the building?
Please enter the occupancy classification of this building.
Do any other tenants occupy this building?
How many tenants occupy this building? (Not including your company.)
What is the square footage of the space your company occupies in this building?
Please provide a description of the other occupancies at this location.
Protection Features
Is the building equipped with fire extinguishers?
Is the building's inspection current?
Does the building have a manual pull box fire alarm system?
Is the manual pull box fire alarm being monitored/supervised?
Does the building have sprinkler protection?
What percentage of the building is sprinklered?
Is the sprinkler system being monitored/supervised?
Does the building have smoke/heat detectors?
Are the smoke/heat detectors being monitored/supervised?
Does the building have a security system?
Is the security system being monitored/supervised?
Does the building have fire hydrants within 1,000 feet?
Does the building have a fire department within five miles?
Exposures
Is the building located in a severe hazard flood zone? (I.e. A, V, etc.)
Is the building located in a high wind prone area? (I.e. coastal)
Does the building have any special hazards that could impact it? (I.e. Earthquake, etc.)
Please provide a brief description of the special hazards that could impact this building.
Please select the term that best describes this building's exposure to risk of physical damage.
Location #2
Do you own or lease this location? *
What is the value of the improvements and betterments made to the leased location(s)?
What is the legal name of the owner of the building?*
What is the address of the location for which you are providing information?*
Construction
Please select the building's construction type.
Please select the term that best describes the condition of the building.
Please select the term that best describes the quality of the building.
What construction material was used for the walls?
What year was the electrical wiring last updated? (YYYY)
Was the electrical wiring update partial or complete?
What year was the plumbing system last updated? (YYYY)
Was the plumbing system update partial or complete?
What year was the heating system last updated? (YYYY)
Was the heating system update partial or complete?
What type of heating system does the building have?
What year was the cooling system last updated? (YYYY)
Was the cooling system update partial or complete?
What type of cooling system does the building have?
What type of fuel does the heating/AC system utilize?
What year was the roof last updated? (YYYY)
Was the roof update partial or complete?
What is this building's roof type?
Please enter the building's roof type.
Does the building have a basement?
Does the building have an attic/penthouse?
What year was the building built? (YYYY)
Has the building been gut renovated since its was built?
What year was the building renovated? (YYYY)
What is the floor height? (In feet)
How many floors/stories does the building have?
What is the total square footage of the building?
What is the square footage of the space your company occupies in this building?
What is the value of the building?
What is the replacement cost of the building?
What is the value of the contents within the building?
Occupancy Classification
What is the occupancy classification of the building?
Please enter the occupancy classification of this building.
Do any other tenants occupy this building?
How many tenants occupy this building? (Not including your company.)
What is the square footage of the space your company occupies in this building?
Please provide a description of the other occupancies at this location.
Protection Features
Is the building equipped with fire extinguishers?
Is the building's inspection current?
Does the building have a manual pull box fire alarm system?
Is the manual pull box fire alarm being monitored/supervised?
Does the building have sprinkler protection?
What percentage of the building is sprinklered?
Is the sprinkler system being monitored/supervised?
Does the building have smoke/heat detectors?
Are the smoke/heat detectors being monitored/supervised?
Does the building have a security system?
Is the security system being monitored/supervised?
Does the building have fire hydrants within 1,000 feet?
Does the building have a fire department within five miles?
Exposures
Is the building located in a severe hazard flood zone? (I.e. A, V, etc.)
Is the building located in a high wind prone area? (I.e. coastal)
Does the building have any special hazards that could impact it? (I.e. Earthquake, etc.)
Please provide a brief description of the special hazards that could impact this building.
Please select the term that best describes this building's exposure to risk of physical damage.
Location #3
Do you own or lease this location? *
What is the value of the improvements and betterments made to the leased location(s)?
What is the legal name of the owner of the building?*
What is the address of the location for which you are providing information?*
Construction
Please select the building's construction type.
Please select the term that best describes the condition of the building.
Please select the term that best describes the quality of the building.
What construction material was used for the walls?
What year was the electrical wiring last updated? (YYYY)
Was the electrical wiring update partial or complete?
What year was the plumbing system last updated? (YYYY)
Was the plumbing system update partial or complete?
What year was the heating system last updated? (YYYY)
Was the heating system update partial or complete?
What type of heating system does the building have?
What year was the cooling system last updated? (YYYY)
Was the cooling system update partial or complete?
What type of cooling system does the building have?
What type of fuel does the heating/AC system utilize?
What year was the roof last updated? (YYYY)
Was the roof update partial or complete?
What is this building's roof type?
Please enter the building's roof type.
Does the building have a basement?
Does the building have an attic/penthouse?
What year was the building built? (YYYY)
Has the building been gut renovated since its was built?
What year was the building renovated? (YYYY)
What is the floor height? (In feet)
How many floors/stories does the building have?
What is the total square footage of the building?
What is the square footage of the space your company occupies in this building?
What is the value of the building?
What is the replacement cost of the building?
What is the value of the contents within the building?
Occupancy Classification
What is the occupancy classification of the building?
Please enter the occupancy classification of this building.
Do any other tenants occupy this building?
How many tenants occupy this building? (Not including your company.)
What is the square footage of the space your company occupies in this building?
Please provide a description of the other occupancies at this location.
Protection Features
Is the building equipped with fire extinguishers?
Is the building's inspection current?
Does the building have a manual pull box fire alarm system?
Is the manual pull box fire alarm being monitored/supervised?
Does the building have sprinkler protection?
What percentage of the building is sprinklered?
Is the sprinkler system being monitored/supervised?
Does the building have smoke/heat detectors?
Are the smoke/heat detectors being monitored/supervised?
Does the building have a security system?
Is the security system being monitored/supervised?
Does the building have fire hydrants within 1,000 feet?
Does the building have a fire department within five miles?
Exposures
Is the building located in a severe hazard flood zone? (I.e. A, V, etc.)
Is the building located in a high wind prone area? (I.e. coastal)
Does the building have any special hazards that could impact it? (I.e. Earthquake, etc.)
Please provide a brief description of the special hazards that could impact this building.
Please select the term that best describes this building's exposure to risk of physical damage.
Vehicle Information
Does your company own any vehicles?
Please provide vehicle information:
Please provide driver information:
Do any of the employees use their personal autos as part of their job requirements?
What is the radius of operations (in miles)?
Staff Information
Does the company have any employees?
Employee Information
Please enter a brief job description for the first employee type.
Please enter the class code for this employee type as listed on your current Workers' Compensation policy, if convenient.
How many full time employees have this job description?
How many part time employees have this job description?
What is the estimated payroll for the employees with this job description?
Is there a second job description to enter?
Please enter a brief job description for the second employee type.
Please enter the class code for this employee type as listed on your current Workers' Compensation policy, if convenient.
How many full time employees have this job description?
How many part time employees have this job description?
What is the estimated payroll for the employees with this job description?
Is there a third job description to enter?
Please enter a brief job description for the third employee type.
Please enter the class code for this employee type as listed on your current Workers' Compensation policy, if convenient.
How many full time employees have this job description?
How many part time employees have this job description?
What is the estimated payroll for the employees with this job description?
Is there a fourth job description to enter?
Please enter a brief job description for the fourth employee type.
Please enter the class code for this employee type as listed on your current Workers' Compensation policy, if convenient.
How many full time employees have this job description?
How many part time employees have this job description?
What is the estimated payroll for the employees with this job description?
Has your employee payroll changed dramatically over the course of the last 12 months?
Please provide a brief description of the reason for the change in payroll. (I.e. New employees, etc.)
Do you allow employees to use your personal vehicle for business use?
What is the projected payroll for the next 12 months?
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Coverage for Partners, Officers, or Relatives
Do you want to INCLUDE/EXCLUDE Partners, Officers, Owners, or Relatives from workers compensation coverage?
Please select the individuals you would like to EXCLUDE from workers compensation coverage.
Please select the individuals you would like to INCLUDE in workers compensation coverage.
Please enter information about the partner(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the partner(s) to be INCLUDED in workers compensation coverage.
Please enter information about the officer(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the officer(s) to be INCLUDED in workers compensation coverage.
Please enter information about the LLC Member(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the LLC Member(s) to be INCLUDED in workers compensation coverage.
Please enter information about the Owner(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the Owner(s) to be INCLUDED in workers compensation coverage.
Please enter information about the relative(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the relative(s) to be INCLUDED in workers compensation coverage.
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Subcontractor Utilization
Does your business utilize subcontractors?
What is the approximate percentage of work that is done by subcontractors? (Ex. 25%)
Is any work sublet without a certificate of insurance from the contractor?
What is the payroll for the subcontractors you do not collect certificates of insurance from?
Do you use written contracts with all subcontractors?
This field is hidden when viewing the form
Claims Information
Have there been any claims in the past three years? *
Please provide a description of any claims from the past three years.
Documents and Comments
Please use this field to upload any relevant insurance documents. (I.e. Current policy declarations pages, appraisals, etc...)
Please enter any additional remarks in the space below.
How did you hear about us?
Please share who referred you to us.
Please share what you typed into Google.
Please share how you heard about us.
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. *
