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Professional-Liability

General Business

General Business Questionnaire

GENERAL INFORMATION

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Do you operate any other type of business or own any other building than listed on this form?
* PLEASE ATTACH COPIES OF YOUR CURRENT POLICY DECLARATIONS PAGES FOR MOST ACCURATE QUOTE *

LOCATION / BUILDING INFORMATION

PROPERTY

Do you rent or loan equipment to others? If Yes, please provide details
► Contents may include, but is not limited to: Leasehold Improvements, Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, and Property of Others in Your Care. Please consult your lease requirements when choosing the coverage and limits for this location.

CRIME

GENERAL LIABILITY

Do you use Subcontractors? If so, explain below work subcontracted
Do you require Subs to have insurance, and do you obtain Certificates of Insurance?

WORKERS COMPENSATION | OWNERS | List below all owners/officers of the business, whether active or inactive in operations

WORKERS COMPENSATION | Please review your current policy for all classes & codes

Do you lease employees to or from other employers? If Yes, please provide details
Do you use volunteers? If Yes, for what type of work?

AUTOMOBILE

Do you rent vehicles for business use?
Do employees use personal vehicles for business?

VEHICLE SCHEDULE | Please complete the below or attach a separate schedule of your own

** Titled/Leased in business name?
** For vehicles not titled/leased in the business name, please indicate the name of the titled owner or lessee for each vehicle

DRIVER SCHEDULE | Please complete the below or attach a separate schedule of your own

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OTHER COVERAGE TO CONSIDER | Would you like more information or a quotation on any of the following?

Umbrella Liability Policy
Employee Benefits Liability
Employment Practices Liability
Directors & Officers Liability
Errors & Omissions Professional Liability
Fiduciary Liability
International
Other Coverage Not Shown

INSURANCE CARRIER HISTORY

Have you had insurance coverage declined, cancelled or non-renewed during the last 3 yrs?

Property & General Liability

Automobile

Workers Compensation

Umbrella

Other

CLAIMS / LOSS INFORMATION

IF CURRENTLY INSURED: PLEASE CONTACT YOUR CURRENT/PRIOR AGENT(s) OR INSURANCE COMPANY(s) FOR A CURRENTLY-VALUED LISTING OF YOUR CLAIMS HISTORY (“LOSS RUNS”) FOR THE PAST 3 YEARS