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Email *
Phone *
Legal Business Name *
Mailing Address Same as Business Address? Select an option Yes No
Entity Type * Select an option Sole Proprietor LLC Corporation Partnership Nonprofit Other
Years in Business * Select an option New Business / Starting Now Less Than 1 Year 1–3 Years 4–10 Years More Than 10 Years
Business Type * Select an option Contractor / Trades Restaurant / Food Service Retail Professional / Office Hospitality / Tourism Property Owner / Lessor Service Business Automotive Technology / E-Commerce Manufacturing / Wholesale Nonprofit / Association Other
Number of Business Locations Select an option 1 2 3–5 More than 5 Not sure
What prompted you to reach out? Select an option New Business Renewal Coming Up Premium Increased Carrier Nonrenewal or Cancellation Buying or Leasing Property Adding Vehicles Hiring Employees Contract or Certificate Requirement Lender or Landlord Requirement Current Coverage Doesn’t Feel Right General Coverage Review Other
Do you currently have business insurance? Select an option Yes No
Have you received a cancellation or nonrenewal notice? Select an option Yes No
Approximate Annual Gross Revenue Select an option Under $100,000 $100,000–$250,000 $250,001–$500,000 $500,001–$1 Million $1 Million–$2.5 Million More Than $2.5 Million
Do customers visit your premises? Select an option Yes No
Do you perform work away from your premises? Select an option Yes No
Do you sell, manufacture, or distribute products? Select an option Yes No
Do you use subcontractors? Select an option Never Occasionally Regularly
Do customers or contracts regularly require certificates of insurance? Select an option Yes No
Anything unusual about your operations we should know about?
Primary Trade Select an option General Contractor Plumbing Electrical HVAC Carpentry Painting Landscaping Snow Removal Roofing Excavation Concrete / Masonry Handyman Other
Type of Work Select an option Residential Commercial Both
Number of Employees Select an option 0 1–2 3–5 6–10 11–25 More than 25
Do you use subcontractors? Select an option No Occasionally Regularly
Approximately what percentage of your work is subcontracted? Select an option Under 10% 10–25% 26–50% More than 50% Not sure
Typical Job Size Select an option Under $5,000 $5,000–$25,000 $25,001–$100,000 $100,001–$500,000 More than $500,000 Varies / not sure
Largest Project Expected During the Next 12 Months Select an option Under $25,000 $25,000–$100,000 $100,001–$500,000 $500,001–$1 Million More than $1 Million Not sure
Any roofing work? Select an option Yes No
Any work above three stories? Select an option Yes No
Any excavation? Select an option Yes No
Any tree removal? Select an option Yes No
Any welding or other hot work? Select an option Yes No
Any snow removal operations? Select an option Yes No
Do you have tools or equipment you want insured? Select an option Yes No
How many business vehicles? Select an option 1 2–5 6–10 11–25 More than 25 Not sure
Typical Operating Radius Select an option Under 25 Miles 25–50 Miles 51–100 Miles More Than 100 Miles Interstate
Primary Garaging ZIP Code
Approximate Number of Regular Drivers Select an option 1 2–5 6–10 11–25 More than 25 Not sure
Do you use hired or rented vehicles? Select an option Yes No
Do employees use personal vehicles for business? Select an option Yes No
Any towing operations? Select an option Yes No
Any delivery operations? Select an option Yes No
Number of Employees Select an option 1 2–5 6–10 11–25 26–50 More than 50 Not sure
Approximate Annual Payroll Select an option Under $100,000 $100,000–$250,000 $250,001–$500,000 $500,001–$1 Million More than $1 Million Not sure
Owner / Officer Coverage Select an option Include Owners / Officers Exclude Owners / Officers Not Sure
Briefly Describe What Employees Do
Do you use subcontractors or 1099 labor? Select an option Yes No
Do you have seasonal employees? Select an option Yes No
Any workers compensation claims during the last five years? Select an option Yes No
Do you own or lease the location? Select an option Own Lease Not sure
Approximate Business Personal Property / Contents Value Select an option Under $25,000 $25,000–$100,000 $100,001–$250,000 $250,001–$500,000 More than $500,000 Not sure
Approximate Tenant Improvements / Betterments Value Select an option None / minimal Under $25,000 $25,000–$100,000 $100,001–$250,000 More than $250,000 Not sure
Approximate Building Value Select an option Under $500,000 $500,000–$1 Million $1 Million–$2.5 Million $2.5 Million–$5 Million More than $5 Million Not sure
Approximate Square Footage
Year Built
Construction Type — if known
Roof Age / Type — if known
Approximate Inventory Value Select an option None / minimal Under $25,000 $25,000–$100,000 $100,001–$250,000 More than $250,000 Not sure
Approximate Equipment Value Select an option Under $25,000 $25,000–$100,000 $100,001–$250,000 $250,001–$500,000 More than $500,000 Not sure
Would a closure materially interrupt your revenue? Select an option Yes No
Fire Sprinklers? Select an option Yes No Not Sure
Central Alarm? Select an option Yes No Not Sure
Type of Operation Select an option Restaurant Bar Café / Coffee Shop Brewery Food Truck Catering Hotel / Lodging Other
Approximate Annual Gross Sales Select an option Under $250,000 $250,000–$500,000 $500,001–$1 Million $1 Million–$2.5 Million More than $2.5 Million Not sure
Approximate Percentage of Sales From Alcohol Select an option None Under 10% 10–25% 26–50% More than 50% Not sure
Seating Capacity Select an option None / takeout only 1–25 26–50 51–100 More than 100 Not sure
Hours of Operation
Open after midnight? Select an option Yes No
Delivery? Select an option Yes No
Catering? Select an option Yes No
Live music or entertainment? Select an option Yes No
Private events? Select an option Yes No
Seasonal operation? Select an option Yes No
Automatic Hood / Fire Suppression System? Select an option Yes No Not Sure
Number of Buildings Select an option 1 2 3–5 More than 5 Not sure
Number of Tenants Select an option 1 2–5 6–10 More than 10 Not sure
Briefly describe tenant types / occupancies
Any Vacancy? Select an option Yes No
Is the owner also an occupant? Select an option Yes No
Approximate Building Square Footage
Approximate Building Value Select an option Under $500,000 $500,000–$1 Million $1 Million–$2.5 Million $2.5 Million–$5 Million More than $5 Million Not sure
Any restaurant or cooking tenant? Select an option Yes No
Any residential units? Select an option Yes No
Do leases require tenants to carry insurance? Select an option Yes No Not Sure
Describe the professional services you provide.
Approximate Annual Revenue Select an option Under $100,000 $100,000–$250,000 $250,001–$500,000 $500,001–$1 Million $1 Million–$2.5 Million More Than $2.5 Million
Address? liability us
How many years have you provided these services? Select an option New / starting now Less than 1 year 1–3 years 4–10 years More than 10 years
Do you use written client contracts? Select an option Yes No
Do you perform work for any particularly large clients? Select an option Yes No
Are you aware of any claim, complaint, dispute, or circumstance that could reasonably result in a claim? Select an option Yes No
Brief optional explanation
Do you accept payment cards? Select an option Yes No
Do you store customer or client personal information? Select an option Yes No
Approximately how many customer/client records do you maintain? Select an option Under 1,000 1,000–10,000 10,001–50,000 More than 50,000 Not sure
Do employees access company systems remotely? Select an option Yes No
Is multi-factor authentication used for email and administrative systems? Select an option Yes No Not Sure
Do you maintain regular backups? Select an option Yes No Not Sure
Any prior cyber incident? Select an option Yes No
Do you currently have umbrella or excess coverage? Select an option Yes No Not Sure
Desired Limit Select an option $1 Million $2 Million $3 Million $5 Million More Than $5 Million Not Sure
Why are you looking for additional liability coverage? Select an option Contract Requirement Landlord Requirement Lender Requirement Additional Protection Current Policy Renewal Not Sure Other
Briefly tell us what happened.
Preferred Contact Method Select an option Call Text Email
Best Time to Reach You Select an option Morning Afternoon No Preference
Anything Else We Should Know?
