Commercial Renewal Questionnaire

BUSINESS INFORMATION

Hidden

Primary Contact

First Last

Hidden

Applicant Name (Name of Business)

Hidden

Primary Email

Who Is Completing This?

First Last

Best Contact Email

Entity Type(Required)

Tax | Federal ID(Required)

Has There Been A Change In Corporate Structure In The Past Twelve Months? (Entity Change | Ownership Change | Etc)(Required)

Describe Corporate Structure Change(s)

Have You Had A Material Change To Your Business Operations In The Last 12 Months?(Required)

Describe How Your Business Has Changed?

Last 12 Months Annual Revenue(Required)

Next 12 Months Annual Revenue (Estimate)(Required)

Do You Have Any Current Employees?(Required)

Number Of Full Time Employess

**Full Time = 30+ Hours Per Week**

Number Of Part Time Employees

**Part Time = Less Than 30 Hours Per Week**

Annual Payroll

Do You Expect To Hire Any Employees?

Do You Plan On Hiring Any Employees In The Next 12 Months?

Number Of Full Time Employees (Next 12 Months)

**Full Time = 30+ Hours Per Week**

Number Of Part Time Employees (Next 12 Months)

**Part Time = Less Than30 Hours Per Week**

Annual Payroll (Next 12 Months)

Do You Use Subcontractors As Part Of Your Workforce?(Required)

Total Cost Of Subcontractors?

Do You Expect To Use Subcontractors In The Next 12 Months?

Total Cost Of Subcontractors (Next 12 Months)?

Do You Have More Than One Business Location?(Required)

List All Location Addresses

Please Include Street Address | City, State Postal Code

TYPE OF COVERAGE TO BE RENEWED

Please Check The Boxes Below That Correspond With The Following Current Renewal

Current Coverage(s) To Be Renewed(Required)

Business Owners

Landlord Or Lessors Risk Coverage (Including Habitational & Commercial)

Business Auto Coverage

Workers Compensation

Business Umbrella Liability

Cyber Liability Coverage

Employment Practices Liability

Professional | E&O Liability Coverage

Bonds | Surety Coverage

Select All That Apply

Business Owners | Commercial Package Coverage

Does (Should) Your Policy Include:

Building Coverage

Business Personal Property Coverage

Tool Coverage

Mobile Equipment And Inland Marine Coverage

Employment Practices Liability Coverage

Check All That Apply

Building Update

If Update Years Aren't Know - Please write "UNKNOWN"

How Much Business Personal Property Do You Need?

Business Personal Property Includes Things Such As: Inventory, Office Equipment, Computer Equipment, Furniture, Etc.

How Much Tool Coverage Do You Need?

Tools Are Not Part Of "Building" or "Equipment" Coverage. These items are typically handheld type tools

Mobile Equipment Update

Mobile Equipment Includes Items Like: Forklifts, Bobcats, Tractors, Etc

Upload Mobile Equipment Listing

Max. file size: 60 MB.

If you have a file that lists the information for your Mobile Equipment, please upload here

Landlord | Lessors Risk Coverage

Lessors Risk Building Update

If Update Years Aren't Know - Please write "UNKNOWN"

Business Auto Coverage

Verify Vehicle & Driver List

Attach Vehicle & Driver List(s) If You Available

Max. file size: 60 MB.

Workers Compensation Coverage

Do You Have Any Out Of State Exposures

Select YES if you have any employees that travel out of state, or live out of state

Other States Information

Owner | Officer Information

Please List All Owners & Officers (Include Ownership %)

Owner/Officer Coverage Selection Or Rejection

Do Owners/Officers Wish To INCLUDE or EXCLUDED For Workers Compensation Coverage