Commercial Insurance Quick Questionnaire

What Insurance are you applying for: (check all that apply)

Workers Comp BOP General Liability Other

Contact Information

Contact Full Name*

Company Name*

Address

Phone:

Office

Cell

Email*

Applicant Information

Legal Entity

Principals Full Name

Title/Position

Are you a new business

Yes No

Number of Years in Business

Number of W2 Employees – Do not include owners

Number of 1099 Employees – Do not include owners

Exclude owners from coverage

Yes No

Payroll

Please provide the gross Annual Payroll for the following

W2 Employees – Do not include owners

1099 Employees – Do not include owners

Owners

Are the owners W2 or 1099?

W2 1099

Current Policy Information

Current Carrier

Policy Period

Classification Code(s)

Brief description of work performed

Experience Modification Factor – Definition - An adjustment of an employer's premium for worker's compensation coverage based on the losses the insurer has experienced from that employer.

Comments

Please email a Copy of most recent 5 year loss run