Property and Casualty Insurance Questionnaire

Proposed Effective Date: * +

Coverage Needed; *

General Liability

Workers'Compensation

Umbrella/Excess Liability

Business Name as it should appear on the policies: * 🛈

First Name *

Last Name *

Email Address *

Phone Number *

Mailing Address *

Address Line 2

City *

State *

Zip Code *

Physical/Street Address *

Address Line 2

City *

State *

Zip Code *

Federal ID Number (FEIN): *

Number of Full-Time Employees *

Number of Part-Time Employees *

Estimated Annual Payroll: *

Estimated Annual Sales: *

Work State: *

What % of work is done on-site? *

Years of Experience *

Description of Operations *

Has your business had any losses in the last 5 years? *

Yes

No

If yes, please provide detail on losses.

If no, please provide a no loss letter on company letterhead.

Please note

This information will be shared with an insurance carrier to determine a pricing indication. In order to bind coverage, a formal application, warranty statement and specific loss information will be required.