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Commercial Questionnaire

Commercial Insurance Request

Name(Required)
Email(Required)
Company Name
Company Structure
MM slash DD slash YYYY
Business Address(Required)
Insurance Services Desired(Required)
Gross sales, if under separate LLC or structure please complete a second form
Percent of Sales for Different types of work, ie: welding, fencing, construction
If multiple locations please give as many details as possible including each location address, staff and position of staff
Please list equipment coverage needs. Welders, tools, etc, for loss coverage
Please provide Auto type, VIN, and Use Is it used for personal needs? Driver information, Date of Birth, Drivers License Number and known claims/ticket history
Coverages Needed Collision, Liability Only, Please Submit Current policy if available (tcastle@farmersagent.com)
Please provide Employee Count and estimated annual payroll
Does Owner Need Workers Comp Coverage Also?

Building Information (if applicable)

Any upstairs or basement area? Are these areas accessible by public?
Last time Roof, Electrical, Plumbing, were updated. Is plumbing PVC or PEX?
Flat Roof, PVC, etc
Please estimate all business personal items, this does not include pin setters or lanes
Please list any and all claims for Liability, Building, Product Liability, as well as any judgements, bankruptcy, felony convictions of owners, basically anything bad...