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Commercial Business Quote Questionnaire

Commercial Business Quote Questionnaire

Commercial Business Quote Questionnaire

Date

MM slash DD slash YYYY

Referred By

Business Name/DBA

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address (if different)

Street Address Address Line 2 City State Zip Code Country

Owner's Name

First Last

Date of Birth

MM slash DD slash YYYY

Phone Number

Email Address

Description of Business

Start Date

MM slash DD slash YYYY

Property

Construction Type

Year Built

Square Footage

Number of Stories

Foundation Type

Personal Property Limit

Most Recent Updates

Electrical

Roof

Plumbing

Heating/Cooling

Is there a boiler?

Yes

No

Is there a sprinkler system?

Yes

No

Is there an alarm system?

Yes

No

General Liability

Annual Receipts

Payroll

Desired Limit of Liability

Any Additional Insureds?

Yes

No

Additional Insureds Details

Sub Contractors

Yes

No

Sub Contractors Details

Workers Compensation

Classification/Jobs

Payroll

Officers

Excluded?

Yes

No

# of Employees

Part Time

Full Time

Additional Information

Current Insurance Carrier

Expiration Date

MM slash DD slash YYYY

Any Losses or Claims Made?

Yes

No

Losses or Claims Details

Additional Coverage

Cyber

Yes

No

Employee Dishonesty

Yes

No

Employment Practices Liability

Yes

No

Umbrella Liability

Yes

No

Automobiles

Liability Limit Desired

# of Vehicles

# of Drivers

Vehicle Information

Vehicle 1

Vehicle 1 Comprehensive

Yes

No

Vehicle 1 Collision

Yes

No

Vehicle 1 Comprehensive Deductible

Vehicle 1 Collision Deductible

Vehicle 1 Roadside Coverage

Yes

No

Vehicle 1 Rental Reimbursement

Yes

No

Vehicle 1 Primary Operator

Vehicle 1 Usage

Vehicle 1 How is Vehicle Titled

Vehicle 2

Vehicle 2 Comprehensive

Yes

No

Vehicle 2 Collision

Yes

No

Vehicle 2 Comprehensive Deductible

Vehicle 2 Collision Deductible

Vehicle 2 Primary Operator

Vehicle 2 Usage

Vehicle 2 How is Vehicle Titled

Vehicle 3

Vehicle 3 Comprehensive

Yes

No

Vehicle 3 Collision

Yes

No

Vehicle 3 Comprehensive Deductible

Vehicle 3 Collision Deductible

Vehicle 3 Primary Operator

Vehicle 3 Usage

Vehicle 3 How is Vehicle Titled

Drivers

Driver 1 Name

First Last

Driver 1 Date of Birth

MM slash DD slash YYYY

Driver 2 Name

First Last

Driver 2 Date of Birth

MM slash DD slash YYYY

Driver 3 Name

First Last

Driver 3 Date of Birth

MM slash DD slash YYYY

Additional Remarks

Location

1793 W Stadium BlvdAnn Arbor, MI 48103

Contact Us

O: 734-327-9222
F: 734-327-9225

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