Commercial Insurance Questionnaire "*" indicates required fields Step 1 of 9 11% Applicant InformationCompany Name*Owner Name(s) & % of ownership - total 100%FEIN / SS#Mailing AddressContact InfoOffice Phone NumberFax NumberCell Phone NumberEmail* Website Year Business StartedDescribe experience if business less than 3 years oldBusiness Type Sole Prop/DBA LLC / LLP C-Corp S-Corp Partnership 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 select the NA for each type of insurance. General Liability & Properety Insurance Co General Liability & Properety Insurance Co Not currently insured. Current Ins AgentExpiration Date MM slash DD slash YYYY Years w/Current CarrierPrior Policy #PremiumCurrent Coverage Information Automobile Not currently insured. Current Ins AgentExpiration Date MM slash DD slash YYYY Years w/Current CarrierPrior Policy #PremiumCurrent Coverage Information Workers’ Comp Not currently insured. Current Ins AgentExpiration Date MM slash DD slash YYYY Years w/Current CarrierPrior Policy #Premium Physical Location #1 InformationPurpose Own Rent Home Office Same Name? Yes No Is the location in the same name business name?AddressCity/State/ZipType of Construction Frame Block/Brick Fire Restive Year BuiltSprinklered? Yes No Sqft of Total BuildingSqft of Your SpaceBuilding Coverage Limit DesiredHave the following building items been updated?Wiring Yes No Plumbing Yes No Heating Yes No Roof Yes No Roof Type and Year UpdatedBusiness Personal PropertyValue of EquipmentAverage Monthly Value of InventoryValue of Furniture & Other ContentsValue of Computer Equip/Soft/DataCost of Betterments & ImprovementsDo you have a second location? Yes No Physical Location #2 InformationPurpose Own Rent Home Office Same Name? Yes No AddressCity/State/ZipType of Construction Frame Block/Brick Fire Restive Year BuiltSprinklered? Yes No Sqft of Total BuildingSqft of Your SpaceBuilding Coverage Limit DesiredHave the following building items been updated?Wiring Yes No Plumbing Yes No Heating Yes No Roof Yes No Roof Type and Year UpdatedBusiness Personal PropertyValue of EquipmentAverage Monthly Value of InventoryValue of Furniture & Other ContentsValue of Computer Equip/Soft/DataCost 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 Annual 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 If the company does not own any vehicles you can still qualify for this coverage option. Number of EmployeesAnnual Rental ExpenseGeneral InformationIf the response should be yes, please choose yes and explain all yes responses. Any 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 countriesAdd explaination for any YES response here.Include an Umbrella/Excess Quote 1,000,000 2,000,000 3,000,000 Not at this time Additional Insured InformationList any entities, such as a client, mortgage holder, landlord, for which proof of insurance must be provided.Description of InterestAdditional Insured’s Name and Mailing AddressAdditional Insured's Fax# / Email Add Remove BUSINESS AUTO INFORMATIONVehicle InformationVEHICLE 1 YearMakeModelBody TypeVIN - Vehicle ID #Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes-Lease Yes-Loan No Cost NewDescription of UseAddress where vehicle is garagedRadius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVWPhysical Damage Coverage? Comprehensive/Collision None If physical damage selected - select deductible 500 1,000 2,500 Do you have another vehicle? Yes No This field is hidden when viewing the formSection BreakVEHICLE 2 YearMakeModelBody TypeVIN - Vehicle ID #Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes-Lease Yes-Loan No Cost NewDescription of UseAddress where vehicle is garagedRadius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVWPhysical Damage Coverage? Comprehensive/Collision None If physical damage selected - select deductible 500 1,000 2,500 Do you have another vehicle? Yes No This field is hidden when viewing the formSection BreakVEHICLE 3 YearMakeModelBody TypeVIN - Vehicle ID #Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes-Lease Yes-Loan No Cost NewDescription of UseAddress where vehicle is garagedRadius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVWPhysical Damage Coverage Comprehensive/Collision None If physical damage selected - select deductible 500 1000 2500 Do you have another vehicle? Yes No This field is hidden when viewing the formSection BreakVEHICLE 4YearMakeModelBody TypeVIN - Vehicle ID #Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes-Lease Yes-Loan No Cost NewDescription of UseAddress where vehicle is garagedRadius of Operation 0-100 mi. 101-200 mi. 201-500 mi. Over 500 mi. GVWPhysical Damage Coverage Comprehensive/Collision None If physical damage selected - select deductible 500 1000 2500 Do you have another vehicle? Yes No This field is hidden when viewing the formSection BreakVEHICLE 5 YearMakeModelBody TypeVin - Vehicle ID #Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes - Lease Yes - Loan No Cost NewDescription of UseAddress where vehicle is garagedRadius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVWPhysical Damage Coverage Comprehensive/Collision None If physical damage selected - select deductible 500 1000 2500 Do you have another vehicle? Yes No This field is hidden when viewing the formSection BreakVEHICLE 6YearMakeModelBody TypeVIN - Vehicle ID #Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes - Lease Yes - Loan No Cost NewDescription of UseAddress where vehicle is garagedRadius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVWPhysical Damage Coverage Comprehensive/Collision None If physical damage selected - select deductible 500 1000 2500 Do you have another vehicle? Yes No This field is hidden when viewing the formSection BreakVEHICLE 7 YearMakeModelBody TypeVIN - Vehicle ID #Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes - Lease Yes - Loan No Cost NewDescription of UseAddress where vehicle is garagedRadius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVWPhysical Damage Coverage Comprehensive/Collision None If physical damage selected - select deductible 500 1000 2500 Do you have another vehicle? Yes No This field is hidden when viewing the formSection BreakVEHICLE 8 YearMakeModelBody TypeVin - Vehicle ID #Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes - Lease Yes - Loan No Cost NewDescription of UseAddress where vehicle is garagedRadius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 200 mi. GVWPhysical Damage Coverage Comprehensive/Collision None If physical damage selected - select deductible 500 1000 2500 Do you have another vehicle? Yes No This field is hidden when viewing the formSection BreakVEHICLE 9 YearMakeModelBody TypeVIN - Vehicle ID #Registered To Insured Yes No Is there a loan/lease on this vehicle? Yes - Lease Yes - Loan No Cost NewDescription of UseAddress where vehicle is garagedRadius of Operation 0-100 mi. 101-200 mi. 201-300 mi. 301-500 mi. Over 500 mi. GVWPhysical 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 EmployeesTotal Number of DriversDriver ListDriver’s Legal NameMale/FemaleDate of BirthDrivers License Number & State Add RemoveAuto 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 InformationPlease read the following questions carefully. If the answer should be yes, please change the answer to yes and provide an explanation at the bottom. A yes may give a credit so please read the questions carefully. Any 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’ Compensation TX Non-subscription / Occupational Accident Other Current Ins AgentExpiration Date MM slash DD slash YYYY Years w/Current CarrierPrior Policy #PremiumEmployer’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 InsuredsDo you operate under more than one company name? List the information here. Additional Named InsuredsFIEN’sENTITY NAME Add RemoveLocationsList locations where employees work other than the main location.LocationsSTREETCITYCOUNTYSTATEZIP CODE Add RemoveRating InformationLocationsList Owners Names% of ownershipInclude or Exclude on Poicy Add RemoveRating InformationLocation Number:Responsibilites or Duties# of Full Time Employees# of Part Time EmployeesAnnual Payroll Add Remove General InformationPlease read the following questions carefully. If the answer should be yes, please change the answer to yes and provide an explanation at the bottom. A yes may give a credit so please read the questions carefully. Years 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 Employees?Average Hourly Wage Clerical/Support Employees?Average Hourly Wage for Sales Employees?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 Remarks Safety ProgramPlease read the following questions carefully. If the answer should be yes, please change the answer to yes and provide an explanation at the bottom. A yes may give a credit so please read the questions carefully. Formal 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 Return To Work to full time modified work Yes No Supervisor accountability plan Yes No Maximum weight lifted manually ______lbs?Protective Equipment provided and enforced? Yes No Machine safety guards in place? Yes No Describe housekeeping?Do you document accidents and the investigation? Yes No Are Records Maintained? Yes No How long are records maintained? Who does the Investigations?Full time Safety Director? Yes No NamePhoneEmail 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 Remarks
