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Business/Commercial Insurance Questionnaire
Please complete the questionnaire to include specific details for an accurate quote. Once you have completed the form you will be contacted by an agent shortly.
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* Indicates required question
Email
*
Your email
Date:
*
MM
/
DD
/
YYYY
Owner's first name (include middle initial, if any)
*
Your answer
Last name
*
Your answer
Company name
*
Your answer
Business legal structure
*
Sole proprietor
LLC
S-Corp
C-Corp
Inc.
Other:
Required
Company email
*
Your answer
Website address
*
Your answer
Business start date
*
Your answer
Years of experience
*
Your answer
Business address (Include city, state and zip)
*
Your answer
Describe business operation
*
Your answer
Provide NAICS code
(www.naics.com)
*
Your answer
FEIN (TaxID)
*
Your answer
List licenses and certifications related to business
*
Your answer
Annual revenue
*
Your answer
Number of owners (include percentage of ownership)
*
Your answer
Number of employees (W2 employees only)
*
Your answer
Estimated annual payroll
*
Your answer
Type of coverage requested (Select all that apply)
*
Business Interruption
Commercial Auto
Commercial Property & Liability
Commercial General Liability
Professional Liability ( E & O)
Worker's Compensation
BOP
Key Person insurance
Business Owner Policy
Other:
Required
Specify limits of coverage
*
ie., General liability - $1,000,000/Aggregate $2,000,000
Your answer
List additional insured, if applicable. Include - full name, organization, full mailing address, email address and phone number.
*
Your answer
Any claims in the past 5 years? If yes, give details.
*
Your answer
For commercial auto indicate radius traveled
*
100 or less
100 or more
500
Other:
List location where work will be performed
*
Your answer
Currently insured? If so, provide name of carrier and expiration date.
*
Your answer
Effective date requested
*
Your answer
Best number to reach you
*
Your answer
Thank you for doing business with us.
Business and Financial Services Advisors
P: 281.845.4452 | Email: info@providenceifs.com
A copy of your responses will be emailed to the address you provided.
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