Commercial Insurance Questionnaire "*" indicates required fields Step 1 of 9 11% Applicant InformationCompany Name* Owner Name(s) & % of ownership - total 100% FEIN / SS# Mailing Address Contact InfoOffice Phone Number Fax Number Cell Phone Number Email* Website Year Bus Started Describe experience if business less than 3 years old Business Type Partnership LLC / LLP Sole Prop/DBA Corp Other Description of OperationsCurrent Coverage InformationCheck the coverage you currently have and list all the information you have regarding your current policy. If you don't have current insurance you can skip this section. General Liability & Properety Insurance Co General Liability & Properety Insurance Co Current Ins Agent Expiration Date MM slash DD slash YYYY Years w/Current Carrier Prior Policy # Premium Current Coverage Information Automobile Current Ins Agent Expiration Date MM slash DD slash YYYY Years w/Current Carrier Prior Policy # Premium Current Coverage Information Workers’ Comp Current Ins Agent Expiration Date MM slash DD slash YYYY Years w/Current Carrier Prior Policy # Premium Physical Location #1 InformationPurpose Own Rent Home Office Same Name? Yes No Address City/State/Zip Type of Construction Frame Block/Brick Fire Restive Year Built Sprinklered? Yes No Sqft of Total Building Sqft of your space Building Coverage Limit Building Updates YrWiring Yes No Plumbing Yes No Heating Yes No Roof Yes No Roof Type and Year Updated Business Personal PropertyValue of Equipment Average Monthly Value of Inventory Value of Furniture & Other Contents Value of Computer Equip/Soft/Data Cost of Betterments & Improvements Do you have a second location? Yes No Physical Location #2 InformationPurpose Own Rent Home Office Same Name? Yes No Address City/State/Zip Type of Construction Frame Block/Brick Fire Restive Year Built Sprinklered? Yes No Sqft of Total Building Sqft of your space Building Coverage Limit Building Updates YrWiring Yes No Plumbing Yes No Heating Yes No Roof Yes No Roof Type and Year Updated Business Personal PropertyValue of Equipment Average Monthly Value of Inventory Value of Furniture & Other Contents Value of Computer Equip/Soft/Data Cost of Betterments & Improvements GENERAL LIABILITYCommercial General Liability (CGL) insurance protects business owners against claims of liability for bodily injury, property damage, and personal and advertising injury (slander and false advertising). Premises/operations coverage pays for bodily injury or property damage that occurs on your premises or as a result of your business operations. Products/completed operations coverage pays for bodily injury and property damage that occurs away from your business premises and is caused by your products or completed work.Select preferred coverage limit per occurrence 500,000 1,000,000 2,000,000 Last Year Estimated Numbers Payroll Gross Sales - Domestic Gross Sales - Foreign Current Year Estimated Numbers Payroll Gross Sales - Domestic Gross Sales - Foreign Next Years Estimated Numbers Payroll Gross Sales - Domestic Gross Sales - Foreign Non Owned / Hired Autos Coverage Options No owned autos Employees use personal vehicles for business Leased or rented vehicles used for business Limit Annual Rental ExpenseGeneral InformationAny medical facilities provided or medical professionals employed or contracted? Yes No Any exposure to radioactive/nuclear materials? Yes No Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc.) Yes No Any operations sold, acquired, or discontinued in last 5 years? Yes No Machinery or equipment loaned or rented to others? Yes No Any aircraft, watercraft, docks, floats owned, operated, hired or leased? Yes No Any parking facilities owned/rented? Yes No Is a fee charged for parking? Yes No Recreation facilities provided? Yes No Is there a swimming pool on the premises? Yes No Any athletic activities, sporting or social events sponsored? Yes No Any structural alterations contemplated? Yes No Any demolition exposure contemplated? Yes No Has applicant been active in or is currently active in joint ventures? Yes No Do you lease employees to or from other employers? Yes No Is there a labor interchange with any other business or subsidiaries? Yes No Are day care facilities operated or controlled? Yes No Have any crimes occurred or been attempted on your premises within the last 3 years? Yes No Is there a formal written safety and security policy in effect? Yes No Does the businesses’ promotional literature make any representations about the safety or security of the premises? Yes No List operations in any other state(s) or countries Include an Umbrella/Excess Quote 1,000,000 2,000,000 3,000,000 Additional Insured InformationList any entities, such as mortgage holder, landlord, for which proof of insurance must be provided.Description of InterestAdditional Insured’s Name and Mailing AddressA/I’s Fax# / Email Add Remove BUSINESS AUTO INFORMATIONVehicle InformationVEHICLE 1 Year Make Model Body Type VIN - Vehicle ID # Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes-Lease Yes-Loan No Cost New Description of UseAddress where vehicle is garaged Radius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVW Physical Damage Coverage? Comprehensive/Collision None If physical damage selected - select deductible 500 1,000 2,500 Do you have another vehicle? Yes No HiddenSection BreakVEHICLE 2 Year Make Model Body Type VIN - Vehicle ID # Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes-Lease Yes-Loan No Cost New Description of UseAddress where vehicle is garaged Radius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVW Physical Damage Coverage? Comprehensive/Collision None If physical damage selected - select deductible 500 1,000 2,500 Do you have another vehicle? Yes No HiddenSection BreakVEHICLE 3 Year Make Model Body Type VIN - Vehicle ID # Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes-Lease Yes-Loan No Cost New Description of UseAddress where vehicle is garaged Radius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVW Physical Damage Coverage Comprehensive/Collision None If physical damage selected - select deductible 500 1000 2500 Do you have another vehicle? Yes No HiddenSection BreakVEHICLE 4Year Make Model Body Type VIN - Vehicle ID # Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes-Lease Yes-Loan No Cost New Description of UseAddress where vehicle is garaged Radius of Operation 0-100 mi. 101-200 mi. 201-500 mi. Over 500 mi. GVW Physical Damage Coverage Comprehensive/Collision None If physical damage selected - select deductible 500 1000 2500 Do you have another vehicle? Yes No HiddenSection BreakVEHICLE 5 Year Make Model Body Type Vin - Vehicle ID # Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes - Lease Yes - Loan No Cost New Description of UseAddress where vehicle is garaged Radius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVW Physical Damage Coverage Comprehensive/Collision None If physical damage selected - select deductible 500 1000 2500 Do you have another vehicle? Yes No HiddenSection BreakVEHICLE 6Year Make Model Body Type VIN - Vehicle ID # Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes - Lease Yes - Loan No Cost New Description of UseAddress where vehicle is garaged Radius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVW Physical Damage Coverage Comprehensive/Collision None If physical damage selected - select deductible 500 1000 2500 Do you have another vehicle? Yes No HiddenSection BreakVEHICLE 7 Year Make Model Body Type VIN - Vehicle ID # Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes - Lease Yes - Loan No Cost New Description of UseAddress where vehicle is garaged Radius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVW Physical Damage Coverage Comprehensive/Collision None If physical damage selected - select deductible 500 1000 2500 Do you have another vehicle? Yes No HiddenSection BreakVEHICLE 8 Year Make Model Body Type Vin - Vehicle ID # Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes - Lease Yes - Loan No Cost New Description of UseAddress where vehicle is garaged Radius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 200 mi. GVW Physical Damage Coverage Comprehensive/Collision None If physical damage selected - select deductible 500 1000 2500 Do you have another vehicle? Yes No HiddenSection BreakVEHICLE 9 Year Make Model Body Type VIN - Vehicle ID # Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes - Lease Yes - Loan No Cost New Description of UseAddress where vehicle is garaged Radius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVW Physical Damage Coverage Comprehensive/Collision None If physical damage selected - select deductible 500 1000 2500 Do you have another vehicle? Yes No Please email the additional vehicle information to commercial@kickerinsuresme.com Lienholder InformationLienholder InformationVEH NO.LIENHOLDER NAME AND MAILING ADDRESSLOAN NUMBER Add RemoveDriver InformationTotal number of Employees Total Number of Drivers Driver ListDriver’s Legal NameMale/FemaleDate of BirthDrivers License Number & StateSocial Security Number Add RemoveAnother page with additional vehicles? Yes No Total Numbers of Vehicles Auto Limits to be QuotedLiability $300,000 $500,000 $1,000,000 Personal Injury Protection (per person) $3,000 $5,000 $10,000 Uninsured/Underinsured Motorists Same as Liability Other Hired Auto Liability None $1,000,000 Other Hired Physical Damage None Limit Comp/Coll Ded $500 Other Non-Owned Auto Liability None $1,000,000 Other Remarks General InformationProvide explanation for all “Yes” responsesAny vehicles owned but not scheduled on this application? Yes No Are all vehicles registered to the named insured? (if not then to who?) Yes No Do over 50% of the employees use their autos in the business? Yes No Is there a vehicle maintenance program in operation? Yes No Are any vehicles leased to the named insured? Yes No Are any vehicles leased to others? Yes No Are any vehicles customized, altered or have special equipment? Yes No Do you have any vehicles that require CDL’s to drive? Yes No Do you have a State or Federal DOT#? Yes No Do you have vehicles that cross state lines? Yes No Are any fillings required i.e ICC, PUC, MCS 90, or others with the FMCA? Yes No Do you carry or transport anything that can be considered a pollutant? (Anything in the wrong place is a pollutant) Yes No Any hold harmless agreements or waiver of subrogation? Yes No Does the owner insure all personal vehicles in the business? Yes No Any vehicles used by family members? If so, identify in Remarks. Yes No Do you obtain MVR’s prior to allowing anyone to drive a company vehicle? Yes No Are all new hires given a driving test prior to driving a company vehicle? Yes No Does the applicant have a specific driver recruiting method? Yes No Are all drivers covered by workers’ compensation including owners? Yes No Are all “autos” on the application including all trailers? Yes No Does your company have an accident investigation process? Yes No Regularly drive vehicles not owned by you? Yes No Accidents/ConvictionsHas any driver shown above had an accident regardless of fault, or been convicted of a moving violation with the last 3 years? Yes No Answer the following questions for each accident/convictionDriverDate of Accident/ ConvictionDescription of Accident/ConvictionPlace of Accident/ConvictionBodily Injury or Death?Dollar Amount of Loss Add RemoveRemarks WORKERS’ COMPENSATION INFORMATIONCurrent Coverage Information Workers’ Comp Other Current Ins Agent Expiration Date MM slash DD slash YYYY Years w/Current Carrier Prior Policy # Premium Employer’s Liability LimitsCurrent Coverage Information $100,000 Each Accident $500,000 Disease-Policy Limit $100,000 Disease Each Employee $500,000 Each Accident $500,000 Disease-Policy Limit $500,000 Disease Each Employee $1,000,000 Each Accident $1,000,000 Disease-Policy Limit $1,000,000 Disease Each Employee Additional Named InsuredsAdditional Named InsuredsFIEN’sENTITY NAME Add RemoveLocationsLocationsSTREETCITYCOUNTYSTATEZIP CODE Add RemoveRating InformationRating InformationSTATELOC #CLASS CODECATEGORIES, DUTIES, CLASSIFICATIONOWNER OFCR INC/EXC# EMPEES FT# EMPEES PTANNUAL FT PT PAYROLL Add Remove General InformationExplain all “Yes” responsesYears in business? Number of Locations? Percent of Employee Turnover the last 12 months? Is this a union shop? Number of permanent employees? Average Hourly Wage for Governing Class? Average Hourly Wage Clerical Class? Average Hourly Wage Sales Class? Number of Part-Time Employees? Number of Temporary Employees? Number of Seasonal Employees? Any work performed underground of above 15 feet? Yes No Any work performed on barges, vessels, docks, bridge over water? Yes No Is applicant engaged in any other type of business? Yes No Are sub-contractors used? (If yes, give % or work subcontracted.) Yes No Any work sublet without certificates of insurance? Yes No Is a written safety program in operation? Yes No Any group transportation provided? Yes No Any employees under 16 or over 60 years of age? Yes No Any seasonal employees? Yes No Is there any volunteer or donated labor? Yes No Any employees with physical handicaps? Yes No Do employees travel out of state? Yes No Are physicals required after offers of employment are made? Yes No Are employee health plans provided? Yes No Is there a labor interchange with any other business/subsidiary? Yes No Do you lease employees to or from other employers? Yes No Do any employees predominantly work at home? Yes No Has the insured ever been in bankruptcy? Yes No Safety ProgramFormal written safety program Yes No Is it IIPP Compliant with SB 198: Yes No Safety Meetings for all Employees Yes No Safety Training for all Employees: Yes No Safety Meetings Documented Yes No Return to work program Yes No RTW to full time modified work Yes No Supervisor accountability plan Yes No Maximum weight lifted manually ______lbs? Prot Equip provided and enforced? Yes No Machine safety guards in place? Yes No Describe housekeeping?Doc accident investigation Yes No Are Records Maintained? Yes No Who does the Investigations?Full time Safety Director? Yes No Name PhoneEmail Health & Wellness Program? DescribeBenefitsProvide explanation for all “Yes” responsesAre all employees Eligible for Company Group Benefits? (if not please explain) Yes No What percentage does the employer pay? What is the percentage of participation? Group Health? Yes No Employer Paid Vacation? Yes No Employer Paid Sick Leave? Yes No Retirement / Pension Plan? Yes No Do you use a specific: Clinic Physician Emergency Room? DescribeCPR training provided? Yes No RemarksUntitled Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice
