Posts Tagged ‘information sheet’

Workers Compensation

Thursday, May 20th, 2010

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Name
Business Name
Street Address
City and Zip
Phone Number
Alternate Telephone
Fax Number
Email Address
Underwriting Information
What is the nature of your business?
What is your business entity
Number of owners or officers
Number of Employees
Payroll of Owners/Officers
Payroll of Employees
Total annual gross receipts
Business License Number
License Type
Years of experience
Years operated under current name
Other business names
Is this business open 24 hours a day?
Any deep frying (food)?
Is there any manufacturing, mixing, re-labeling or repackaging of products?
Is there filling of propane tanks?
Please describe the nature of your business and ANY unusual exposures:
Payroll Detail Information
Employee Group 1
Class / Code
Payroll Rate
Annual Payroll
Employee Group 2
Class / Code
Payroll Rate
Annual Payroll
Employee Group 3
Class / Code
Payroll Rate
Annual Payroll
Employee Group 4
Class / Code
Payroll Rate
Annual Payroll
Employee Group 5
Class / Code
Payroll Rate
Annual Payroll
Claims Information
Were there any losses or claims in the last 5 years?
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
Current Insurance Company
How much are you paying now?
What is the liability limit requested?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:

Restaurant Insurance Quote

Thursday, May 20th, 2010

Please take a few minutes and compete the following information if you would like to obtain a quote.   Please understand, this is not an application.   An application will be provided to you if coverage is desired.

All information given on this form is confidential and will be used solely for the purpose of developing a quote for you.

Name
Business Name
Street Address
City and Zip
Phone Number
Alternate Telephone
Fax Number
Email Address
What is the business entity
Property Information
Property Street Address
City and Zip
Total square footage of the building your business is in
Total square footage of your business only
Total square footage of the customer area only
How many stories is it?
If it's two stories, what is the ground floor square footage?
What is the construction type?
What type of roof covering?
Was the roof updated?
If yes, what year?
What is the distance to fire protection?
Do you have a storage area more than 1500 Sq. Ft.?
Are there smoke detectors at this location?
Are there fire extinguishers?
Does the building have interior automatic fire sprinklers?
Is there a fire alarm?
Is there a theft alarm?
Are there deadbolts on all doors?
Are there circuit breakers?
Is the electrical updated?
Is the heating / air conditioning thermostatically controlled?
Is the heating/ air conditioning central?
Has the plumbing been updated?
If yes, what year?
Is the parking lot under your protection?
Underwriting Information
What is the nature of your business?
Number of owners
Number of Employees
Payroll of Owners
Payroll of Employees
Total annual gross receipts
Total annual hard liquor receipts
Total annual beer and wine receipts
Total annual food gross receipts
Business License Number
License Type
Years of experience
Years operated under current name
Is this business open 24 hours a day?
Is there filling of propane tanks?
Please describe the nature of your business and ANY unusual exposures:
Entertainment Information
Is there entertainment?
If yes, please describe
Is there live music?
If yes, what size is the dance floor and how many nights per week is there dancing?
Are there any coin operated amusement devices?
If yes, please describe
Are there any pool tables?
If yes, how many and are they coin operated?
Are there any bouncers, doormen, ID checkers, armed or security guards?
If yes, how many of each? (list their job duties and employer)
Are there any contests or exhibition?
If yes, describe events.
Are there any audience participation events?
If yes, describe events.
Do you sponsor any sporting events?
If yes, describe events.
Do you have any other type of entertainment?
If yes, describe events.
Cooking Information
Describe the cooking devices at your business.
Is there tableside cooking?
Is there an automatic suppression system?
If yes, do they protect all hoods, ducts and griddles?
Is there any deep frying?
If yes, is there a high limit shutoff?
Do you have an outside cleaning service for the hoods and duct system?
How often are hood and duct cleaned?
Is there any manufacturing, mixing, re-labeling or repackaging of products?
Is there any delivery service?
Is there any catering service?
Miscellaneous and Claims Information
Were there any losses or claims in the last 5 years?
If yes, what is the date, amount paid and description of each loss or claim?
Current Insurance Company
How much are you paying now?
What is the renewal date?
Has insurance ever been cancelled?
If yes, describe.
Have you ever had regulatory violations or citations?
Are employees trained on how to handle minors or intoxicated customers?
If yes, describe.
Coverage Information
What building coverage is requested?
What other structures is requested?
What business contents is requested?
What is the loss of use coverage requested?
What is the liability limit requested?
What policy deductible is requested?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:

Personal Umbrella Quote

Thursday, May 20th, 2010

Plase take a few moments to complete the following information if you would like to obtain a quote.  Please understand, this is not an application.   If coverage is desire, an application will be sent to you.

All information provided is confidential and will be used solely for the purpose of providing a quote for you.

Name
Business Name
Street Address
City and Zip
Phone Number
Alternate Telephone
Fax Number
Email Address
Underwriting Information
Are any aircraft owned, leased, chartered or furnished for regular use?
Do any drivers have mental or physical impairments?
Are any premises, vehicles, watercraft, aircraft used for business?
Are any premises, vehicles, watercraft, aircraft owned, hired, leased or regularly used not covered by the primary policies?
Do you engage in any type of farming operation?
Do you hold any non-remunerative positions?
Any non-owned property exceeding $1,000 in value in your care, custody or control?
Any non-owned business or professional activities included in the primary policies?
Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures?
Was any coverage declined, cancelled or non-renewed within the past 5 years?
Any motorcycles, mopeds or all terrain vehicles owned?
Any other business activities conducted from your residence or premises?
Please explain any YES answers from above
Driver 1 Information
Name
Gender
Marital Status
Years Licensed
State Licensed
Occupation
Driver 2 Information
Name
Gender
Marital Status
Years Licensed
State Licensed
Occupation
Driver 3 Information
Name
Gender
Marital Status
Years Licensed
State Licensed
Occupation
Driver 4 Information
Name
Gender
Marital Status
Years Licensed
State Licensed
Occupation
Violation Information - Last 3 years (minor violations) / Last 5 years (major violations)
Driver 1
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 2
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 3
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 4
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Miscellaneous and Claims Information
What is the number of single family dwellings you own?
What is the number of autos you own?
What is the number of recreational vehicles you own?
What is the number of multi-unit buildings you own?
What is the number of vacant property (land) you own?
What is the number of motorcycles you own?
Were there any losses or claims in the last 5 years?
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
Current Insurance Company
How much are you paying now?
What is the liability limit requested?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:

Home Business Quote

Thursday, May 20th, 2010

Please take a few minutes to complete the following information if you would like to obtain a quote.  Please understand, this is not an application.   If coverage is desired, an application will be sent to you.

All information provided is confidential and will be used solely for the purpose of providing a quote for you.

Commercial General Liability Quote

Thursday, May 20th, 2010

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Name
Business Name
What is business entity
Street Address
City_and_State
Phone Number
Alternate Telephone
Fax Number
Email Address
Location 1 Detail Information
How many full time employees?
How many part time employees?
Location 2 Detail Information
Street Address
City and State
How many full time employees?
How many part time employees?
Location 3 Detail Information
Street Address
City and Zip
How many full time employees?
How many part time employees?
How many seasonal employees?
Underwriting Information
Describe is the nature of your business?
Number of owners or officers
Annual owners/officers salary
Annual employees salaries
Total annual gross receipts
Years in business
Is this business open 24 hours a day
Are you aware of any claim situation not filed?
Has there been a company merger within the last 24 months?
Claims Information
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
Current Insurance Company
How much are you paying now?
What is the liability limit requested?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:

Artisan Contractor Quote

Thursday, May 20th, 2010

Please take a few minutes to complete the following information if you would like to obtain a quote.  Please understand, this is not an application.  If coverage is desired, an application will be sent to you.

All information provided is confidential and will be used solely for the purpose of providing a quote for you.

Name
Business Name
Business Entity
Street Address
City and Zip
Phone Number
Alternate Telephone
Fax Number
Email Address
Underwriting Information
Number of owners or officers
Number of Employees
Payroll of Owners/Officers
Payroll of Employees
Total annual gross receipts
Do you use subs?
Total annual sub costs
Do you require your subs to provide you insurance certificates equal to your liability limits
Describe all work performed
License Number, if any
License Type, if any
Years of experience
Years operated under current name
Other business names
Do you construct footings or foundations which may support dwellings or other structures?
Do you construct slab or monolithic floors?
Do you construct piers or underpinning which may support dwellings or other structures?
Do you construct retaining walls which may support dwellings or other structures?
What is the percentage of work done as a General Contractor?
What is the percentage of work done as a Sub-Contractor?
What is the percentage of work done on Residential?
What is the percentage of work done on Commercial?
What is the percentage of work done for Remodeling?
What is the percentage of work done for New Construction
What is the percentage of work done for Repair or Maintenance?
Claims Information
Were there any losses or claims in the last 5 years?
If yes, what is the date, amount paid and description of each loss or claim?
Current Insurance Company
How much are you paying now?
What is the liability limit requested?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:

Business Owners’ Quote

Thursday, May 20th, 2010

Please take a few minutes to complete the following information if you would like to obtain a quote.  Please understand, this is not an application.  If coverrage is desired, we will send an application to you.

All information provided is confidential and will be used solely for the purpose of providing a quote for you.

Name
Business Name
Street Address
City
State
Zip Code
Phone Number
Alternate Telephone
Fax Number
E-Mail Address
Underwriting Information
What is the nature of your business?
What type entity is the business
Number of Owners or Officers
Number of Employees
Total Annual Payroll of Owners or Owners
Total Annual Payroll of Employees
Total Annual Gross Receipts
Business License Number, if any
License Type, if any
Years of experience
Years operated under current name
Other business names
Is there any manufacturing, mixing, re-labeling or repackaging of products?
Please describe the nature of your business and ANY unusual exposures:
Building & Property Information
Dor You Own the Building or Lease
What is Age of Building
Total square footage of the building your business is in
Total square footage of your business only
How many stories is it?
If two stories, what is the ground floor square footage?
What is the construction type?
What type of roof covering?
Was the roof updated, if owner?
If yes, what year?
Are there smoke detectors at this location?
Are there fire extinguishers?
Are there deadbolts on all exterior doors?
Is the electrical updated?
Is the heating / air conditioning thermostatically controlled?
Is the heating/ air conditioning central?
Has the plumbing been updated?
If yes, what year was the plumbing updated?
Does the building have interior automatic fire sprinklers?
Is there a theft alarm?
Is there a fire alarm?
Claims Information
Were there any losses or claims in the last 5 years?
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
Current Insurance Company
How much are you paying now?
What is the liability limit requested?
What is the building limit requested?
What is the building deductible requested?
What is the business personal property (contents) limit requested?
What is the contents deductible requested?
What is the loss of income requested?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:

Commercial Vehicle Quote

Thursday, May 20th, 2010

Please take a few minutes and complete the following information if you would like to obtain a quote.  Please understand, this is not an application.  If coverage is desired, an application will be sent to you.

All information provided is confidential and will be used solely for the purpose of providing a quote for you.

Name of Business
Business Entity
Name of person to contact
Garaging Street Address
City and Zip
Phone Number
Alternate Telephone
Fax Number
Email Address
Mailing Address - if different from above
Street Address
City and Zip
Driver 1 Information
Name
Gender
Marital Status
Years Licensed
State Licensed
License Type
Driver 2 Information
Name
Gender
Marital Status
Years Licensed
State Licensed
License Type
Driver 3 Information
Name
Gender
Marital Status
Years Licensed
State Licensed
License Type
Driver 4 Information
Name
Gender
Marital Status
Years Licensed
State Licensed
License Type
Vehicle 1 Information
Year
Make
Model
VIN
G.V.W.
Miles per Year
Radius Driven (Average)
Ownership
Vehicle 2 Information
Year
Make
Model
VIN
G.V.W.
Miles per Year
Radius Driven (Average)
Ownership
Vehicle 3 Information
Year
Make
Model
VIN
G.V.W.
Miles per Year
Radius Driven (Average)
Ownership
Vehicle 4 Information
Year
Make
Model
VIN
G.V.W.
Miles per Year
Radius Driven (Average)
Ownership
Violation Information - Last 3 years (minor violations) / Last 5 years (major violations)
Driver 1
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 2
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 3
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 4
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Coverage Information
Personal Liability / Bodily Injury
Personal Liability / Property Damage
Uninsured Motorist / Bodily Injury
Uninsured Motorist / Property Damage
Medical Payment
PIP (Personal Injury Protection)
Deductible Information
Vehicle 1
Comp (Theft)
Collision
Vehicle 2
Comp (Theft)
Collision
Vehicle 3
Comp (Theft)
Collision
Vehicle 4
Comp (Theft)
Collision
Miscellaneous InformationMiscellaneous Information
Current Insurance Company
Expiration Date
Current Premium
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:

Auto Insurance Quote

Thursday, May 20th, 2010

Please take a few minutes to complete the following information if you would like to obtain a quote on an Auto insurance policy.  Please understand, this is not an application for insurance.  If coverage is desired, an application will be sent to you.

All information provided is confidential and will be used solely for the purpose of providing a quote for you.  Please be aware that credit scoring is used by most insurance companies, and is necessary for an accurate quote.  Please know that this is a soft hit to your credit and will not effect your credit score.

Name
Garaging Street Address
City and Zip
Phone Number
Alternate Telephone
Fax Number
Email Address
Mailing Address - if different from above
Street Address
City and Zip
Driver 1 Information
Name
Gender
Birth Date
Social Security Number
Drivers License Number
Marital Status
Occupation
Driver 2 Information
Name
Gender
Birth Date
Social Security Number
Drivers License Number
Marital Status
State Licensed
Occupation
Driver 3 Information
Name
Gender
Birth Date
Social Security Number
Drivers License Number
Marital Status
State Licensed
Occupation
Driver 4 Information
Name
Gender
Birth Date
Social Security Number
Drivers License Number
Marital Status
State Licensed
Occupation
Vehicle 1 Information
Year
Make
Model
Vin #
Miles per Year
Ownership
Vehicle 2 Information
Year
Make
Model
Vin #
Miles per Year
Ownership
Vehicle 3 Information
Year
Make
Model
Vin #
Miles per Year
Ownership
Vehicle 4 Information
Year
Make
Model
Vin #
Miles per Year
Ownership
Violation Information - Last 3 years (minor violations) / Last 5 years (major violations)
Driver 1
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 2
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 3
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 4
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Coverage Information
Personal Liability / Bodily Injury
Personal Liability / Property Damage
Uninsured Motorist / Bodily Injury
Uninsured Motorist / Property Damage
Medical Payment
Deductible Information
Vehicle 1
Comp (Other Than Collision)
Collision
Vehicle 2
Comp (Other Than Collision)
Collision
Vehicle 3
Comp (Other Than Collision)
Collision
Vehicle 4
Comp (Other Than Collision)
Collision
Miscellaneous InformationMiscellaneous Information
Current Insurance Company
Expiration Date
Current Premium
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other: