General Insurance Questionnaire

Please complete the below form to the best of your ability so that our team can understand the unique nature of your business and identify your insurance needs.

Named Insured

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name

First Name

Last Name

Phone

(###)

###

####

Description of Business

Website

http://

Proposed Effective Date

YYYY

Years in Business

Years in Industry (If in business less than 3 years)

Estimated Annual Receipts / Sales

Estimated Annual Payroll

Number of Full Time Employees

Number of Part Time Employees

Number of Male Employees

Number of Female Employees

Location Address (If differs from Mailing Address)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Construction of Building

Number of Stories

Year Building Built

Insured Square Footage

Is Insured Space Sprinklered?

Any Aluminum Wiring

Year of Last Update - Roof

Year of Last Update - Electrical

Year of Last Update - Plumbing

Year of Last Update - Heating

Central Station Fire Alarm?

Building Limit Value

Enter 0 if you do not own the building

Improvements and Betterments Limit

Business Personal Property Limit

Annual Business Income Limit

Desired Property Deductible

Name and Address of Landlord

If applicable

Disclosure