JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Financial Advisor - Questionnaire
Please fill in to the best of your ability the following information. T
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Your answer
Contact Email
*
Your answer
Contact Phone
*
Your answer
Location Full Address, City, State, Zip, Country
*
Your answer
Business Website
Your answer
Business Type
Sole Proprietor
Corporation
Partnership
LLC
Other
Clear selection
Business Square Footage
Your answer
Annual Gross Receipts
Your answer
Number of Employees
Your answer
Years In Operation
Your answer
Years Insured? And current Carrier
*
Your answer
If Contractor, insured for 2 years?
Yes
No
Occupant
Owner - Lessor
Owner - Occupied
Tenant
Business in the Home
Clear selection
SSN# or Fed ID#
Your answer
Year Built
Your answer
Construction
Frame
Masonry Veneer
Masonry
Masonry Noncombustible
Noncombustible
Fire Resist
Discounts
100% Sprinklered
Enclosed Building
Protective Devices
Local Pull Station Fire Alarm
Local Burglar Alarm
Central Station and Proprietary Burglar Alarm
Fire or Smoke Central Alarm
Security Guard
Claims within the past 3 years?
*
Yes
No
If yes, Type and Amount of loss(es)?
Your answer
Deducible
Your answer
Building Value?
Your answer
Business Content Value? (Includes merchandise, stock, owned and leased furniture & equip, phones, copiers, do not include computer values)
Your answer
Value of any tenant betterments and improvements?
Your answer
Liabilities?
Your answer
Medical Expense Coverage
Your answer
Restaurants: Percent of alcohol sales to total sales?
Your answer
Restaurants: Automatic Extinguishing system (AES): Date last serviced
Your answer
Restaurants: AES Servicing Contractor?
Your answer
Do you need coverage for loss of sums that are uncollected due to damage of Account Receivables?
Yes
No
Clear selection
If yes, What amounts are needed? On Premises? Off Premises?
Your answer
Is it important for you to have coverage to business personal property that is damaged due to water backing up from a sewer or drain? (min cov is 20% of cont amt - max is 50% of cont amt up to $100,000)
Yes
No
Clear selection
(For building coverage only) Code enforcement may require that undamaged portions of a damaged building be torn down if a building is heavily damaged. Is it important to you to have coverage that would pay to replace the undamaged portion
of the building?
Yes
No
Clear selection
(For building coverage only) Is it important to you to have coverage that would pay for increased costs to repair your building resulting from ordinances regulating the construction of buildings?
Yes
No
Clear selection
If Yes , what percentage
10%
25%
50%
100%
Clear selection
What is the value of all computer equipment, data & media owned or leased? Deductible ($500 min)
Your answer
(Can only be purchased with Computer Property coverage) Would you suffer a loss of income if your computers were not operating due to a covered computer loss?
Yes
No
Clear selection
If yes, provide the amt of income you could lose?
Your answer
Is it important to have coverage for employee theft?
Yes
No
Clear selection
Number of Employees?
Your answer
If Yes, Provide Coverage Amount
$5000
$10,000
$25,000
$50,000
Clear selection
How much is your sign worth?
Your answer
Do you need comp & collision coverage for customer's vehicles in your care, custody & control?
Yes
No
Clear selection
Do you need coverage for liability arising out of the use of customer owned autos?
Yes
No
Clear selection
Need liability cov for vehicles rented by the business?
Yes
No
Clear selection
If Yes, Provide amount spent per year to rent
Your answer
Is it important to have coverage for theft of cash?
Yes
No
Clear selection
If Yes, what is the most you have on hand? On Premises and Off Premise.
Your answer
Do you need a 40% increase of business personal property to provide for seasonal variations? (Not available for Rel Org, Apart, Condo)
Yes
No
Clear selection
Do you have property of others in your control?
Yes
No
Clear selection
If Yes, provide value
Your answer
Do you need cov for loss of merchandise caused by temp change resulting from fluctuation or total interruption of electric power or mechanical breakdown of refrigeration/heating equipment?
Yes
No
Clear selection
If yes, provide value of these items
Your answer
Is it important for you to have coverage that would pay for your loss of income if your business had to be closed due to failure of communications, water, natural gas, or electrical service caused by a specified cause of loss away from your business premises?
Yes
No
Clear selection
If Yes, how much
$10,000
$20,000
$30,000
Clear selection
Do you need coverage to research and replace valuable papers?
Yes
No
Clear selection
What are the costs On Premises and Off Premises?
Your answer
Worker's Compensation or Contractor Policies:
Work Comp: be sure to include below all officer/owner payroll that will be covered by this policy
Years Insured for Worker's Comp:
Your answer
Workers Comp Claim History
0
1
2
3
4+
Clear selection
Please list out any job duties and payroll amount as well as any subcontractor duties and total costs
Your answer
Business Auto
If able to obtain the current dec page/vehicle listing, only necessary to provide Radius of Operation, Vehicle Use, and Loan Amount fields for each vehicle
below. Additional vehicles may be added to the Vehicle Addendum if necessary.
Employees drive own cars
for the business?
Yes
No
Clear selection
Do you rent/lease cars for business purposes?
Yes
No
Clear selection
Estimated Yearly Cost of Rentals?
Your answer
Provide Coverage Requests Answers Below
Pip Limit:
Med Pay Limit:
BI/PD Limits:
UM Limit:
Physical Damage Coverage: Comp/Collision Ded:
Value of Attached Equipment$
Your answer
Any major violations by drivers within the last three years?
Yes
No
Clear selection
Do you need more liability coverage than what is provided under the business liability policy?
Yes
No
Clear selection
Specialty Products
Employment Practices Liability (EPLI)
Accountants Professional
Architects/Engineers Professional
Dentists Professional
Technology Services E&O
D&O
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of 11 DIGITAL.
Report Abuse
Forms
