Home > New Business Quote Questionnaire

New Business Quote Questionnaire

Policy or Account Number this quote is associated with:

Name Insured:

Mailing Address:

Location Address:

City:

State:

Zip:

Fax #:

Phone #:

Email Address:

Owner's Name

Branch and Agency Producer Code

Effective Date

Legal Entity

Number of Employees

WORKERS COMPENSATION

FEIN Number

Tax ID Number

Limits of Insurance

Each accident

Disease Policy Limit

Disease-Each Employee

Annual Payoll

Class Code

Offer Exclusion

Contact person & best time to contact

Years in business (Mandatory)(Required)

Previous Carrier Info for All Lines Business or 3 years Managerial Experience to Include Name of Carrier, Policy Number, Expiration Date and Experience Mod (If Any) and/or copy of current policy

Any losses in the last 3 years? If yes please describe on separate sheet (if necessary) or provide Loss Runs from your current Insurance Company and/or describe below.

PROPERTY

Contents Limit – What are you currently insured for?

Building Limit – Occupancy type

Is this a Lessor’s Risk?

Yes

If so, who are the occupants?

% occupied by insured

% occupied by tenant

Total area occupied by insured

Area occupied by tenant

Deductible - $500, $1,000 (LRO Default), $2,500, $5,000, $10,000 $25,000

Building construction type (Frame, Concrete or Brick, Steel, Fire Resistive)

Year the building was built

Is the building over 25 years old?

Updates

Roofing

Plumbing

Electric

Heating/AC

Sprinkler 100%

Square Feet Occupied

% of Area Occupied

# of Stories

Burglar Alarm System

Employee Dishonesty requires # of Employees

Full Time

Part Time

GENERAL LIABILITY

Liability Limits

1,000,000 / 2,000,000

2,000,000 / 4,000,000

Gross Annual Sales for all Location’s

Payroll

Stop Gap (State)

EPLI

# of Employees

Employee Benefits Liability

Hired and Non-Owned Auto Liability Coverage

Yes

UMBRELLA

Limit of Liability

Is there an existing Umbrella?

Yes

U/L Carrier Name and Limits for Auto or WC (If not CNA

(Note: Please provide copy of declaration page, if available)

Attach File/s Here

Max. file size: 49 MB.

BUSINESS AUTO

Remember the vehicles must be registered in the Name of the Company.
If Insured requires a Quote for Business Auto Coverage other than the Hired and NonOwned Coverage, please obtain the information below.

Federal ID #

Combined Single Limit of Liability

Hired/Auto & Non/Owned Auto Liability

Personal Injury Protection

Options:

Uninsured/Underinsured Motorists Limit

Medical Payments Limit

Hired Auto Physical Damage Limits & Deductible

Vehicle 1 Information

Vehicle #

VIN#

Cost New $

List

Make

Model

Year

Type

List

Comprehensive Deductible ($)

Collision Deductible ($)

Garage Location

Towing (PPT’s Only)

Rental Reimbursement

Vehicle 2 Information

Vehicle #

VIN#

Cost New $

List

Make

Model

Year

Type

List

Comprehensive Deductible ($)

Collision Deductible ($)

Garage Location

Towing (PPT’s Only)

Rental Reimbursement

Vehicle 3 Information

Vehicle #

VIN#

Cost New $

List

Make

Model

Year

Type

List

Comprehensive Deductible ($)

Collision Deductible ($)

Garage Location

Towing (PPT’s Only)

Rental Reimbursement

Please provide the following information on all Drivers.

List

Full Name Violations

DOB

License Number & State

Loss Payee &/or Additional Insured:

Name

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

New Business Quote Questionnaire

We Want Your Opinion!

Customer Reviews