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Request a Quote

General Business Insurance Questionnaire

Applicant Information
(Required *)

How did you hear about MOODY Insurance?
If you have a MOODY representative in mind please list them to the right:
Complete Business Name: *
Mailing Address/Street:
City:
State:
Zip:
Location Address/Street (if different from mailing):
City:
State:
Zip:
Primary Contact Name: *
Contact Title:
Phone Number: *
Fax Number:
Email Address: *
Web Site Address:
Type of Entity
(Sole Proprietor, Corporation, Partnership, LLC, etc):
Federal ID Number:
Date Business Started:
Prior Business Experience for businesses open less than 3 years:
   
Type of Business:
Select from the industry groups to the right:		 Information Technology
Biotechnology
Maids – Residential cleaning services
Plastics manufacturing
Not for profit
Other
Describe typical services performed, customers served, products provided, etc.:
Do you set standards or provide any certifications? No Yes
Do you work or sell product overseas? Yes       No
   
Current Insurance Information
Current Insurance Carrier (Name of Company, not Agency):
How Long Insured:
Date(s) Policy(s) Expire:
Reason for Seeking New Carrier:
Details of Losses/Claims over the Last 3 Years:
Note: Complete loss information below or send loss runs to customerservice@moodyinsurance.com or Fax (301) 417-0040.
   
Location / Building Information
  LOCATION 1 LOCATION 2 LOCATION 3
Construction:
# of Stories:
Year Built (approx.):
If over 30 years old, years of updating for
Wiring
Heating
Plumbing
Roof
Wiring
Heating
Plumbing
Roof
Wiring
Heating
Plumbing
Roof
Square Footage:
Owner? No Yes No Yes No Yes
Tenant? No Yes No Yes No Yes
Alarms? Burglar
Fire
Local
Central Station		 Burglar
Fire
Local
Central Station 		Burglar
Fire
Local
Central Station
Sprinklers? No Yes No Yes No Yes
   

Coverage/Rating Basis Information
Property
Replacement Value of Contents:
Should include Leasehold Improvements(may also be included in building so obtain a breakdown), Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, Property of Others
 $
Replacement Value of Building, if applicable: $
Replacement Value of Computer Hardware: $
Valuable Papers: $
Property Used at Exhibitions, Fairs or Tradeshows: $
Other property or equipment (specify type of property and value):
Business Property Used/Transported/Stored Off-Premises: $
Exterior Sign?: No Yes
Exterior Glass? No Yes
Business Income: $
 
General Liability
Each Occurrence Limit Desired: $
Estimated Annual Gross Revenues: $
Estimated Annual Total Payroll $
Number of Full Time Employees:
Number of Part Time Employees:
Do you use sub-contractors?: No Yes

If yes, for what purposes?:

Do you require sub-contractors to carry insurance and do you obtain certificates of insurance?:

No Yes
 
Worker's Compensation by State
State Classification/Duties:   Est. Annual Payroll:  Number of Employees:
$
  Classification/Duties   Est. Annual Payroll:  Number of Employees:
$
  Classification/Duties   Est. Annual Payroll:  Number of Employees:
$
  Classification/Duties   Est. Annual Payroll:  Number of Employees:
$
 
Owner/Officer Information
Name   Title  Duties  Incl/Excl
Name   Title  Duties  Incl/Excl
Name   Title  Duties:  Incl/Excl
Name   Title  Duties  Incl/Excl
 
Automobile
Comprehensive Deductible: $
Collision Deductible: $
Rented Vehicles used or Employee Vehicles Used in Business? No Yes

If yes, number of rental car days/year:

If non-owned, how many employees drive their cars frequently for company business:
If any key employees have company vehicles and do not buy a personal auto policy for their protection while driving for personal use (Drive Other Car Coverage ), list their names:
   
Owned Vehicle Schedule
NOTE: Complete below with vehicles and drivers or send your lists to customerservice@moodyinsurance.com or Fax (301) 417-0040.

YEAR

MAKE / MODEL

COST NEW

GARAGING CITY/STATE

RADIUS

USE in YEARS

Drivers Schedule (if you own vehicles)
(List all employees who drive any vehicle on company business).

NAME

DATE OF BIRTH

DRIVERS LIC #

STATE

ACCIDENTS/VIOLATIONS WITHIN LAST 3 YEARS
 
Prior Claim/Loss Information

Have you had any prior claims or losses? No Yes

IMPORTANT: IF YOU ANSWERED YES ABOVE, PLEASE CALL YOUR CURRENT AGENT AND REQUEST A COPY OF YOUR CLAIMS HISTORY (OR “LOSS RUNS”) FOR THE LAST THREE YEARS FOR ALL OF YOUR POLICIES.
 
Other Optional Coverage to Consider
Do you need coverage for trips or work outside the United States? No Yes
Would you like an optional Umbrella Quote? No Yes
Would you like an Employee Benefits Quote (health, life, disability, long-term care)? No Yes
Would you like an Employment Practices Liability Quote? No Yes
Interested in Any Other Coverage Not Shown Above?
 
        



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