1. P&C Questionnaire
1. Business Name:_________________________________________________________________________
Address:_______________________________________________________________________________
City, County, State & Zip Code:____________________________________________________________
Primary Contact:____________________________________Phone:_______________Fax:_____________
2. Type of Business:________________________________________________________________________
3. Class of Business & Description:____________________________________________________________
4. Type of Legal Entity:________________________ 5. FEIN #___________________________
6. Year Business Started: _____________ 7. Hours of Operation: _____________________________
8. Is this a home-based business? Yes No
9. # of Employees: Full-Time_______ Part-Time________
10. Gross Annual Payroll (excluding owners): ______________________
11. Gross Annual Sales/Receipts: ____________________________
12. Does this business own any other business? Yes No
13. Is this business a subsidiary of another company? Yes No
14. Does the business have any outstanding suits, liens or judgements against it? Yes No
15. Is the business currently bankrupt, or in the process of filing for bankruptcy? Yes No
16. Any athletic teams sponsored? Yes No
Location Information
Year Built _________ Building Construction Type ______________________ Total Square Footage________
Square Footage Occupied____________ # of Stories ____ # of Basement Levels ____ Protection Class ____
If Building is more than 15 years old, Year improvements made to: Roof _____ Wiring ______ Heating _____
Plumbing _______ Total Renovation Year ___________ Percentage of Building Sprinklered __________
Burglar or Fire Alarm? Type ____________________________________________
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2. Landlord Information if rented (Name, Address, City, State & Zip Code):
__________________________________________________________________________________________
Name as Additional Insured? Yes No
Additional Insured Information (Name, Address, City, State & Zip Code):
__________________________________________________________________________________________
Insurable Interest: __________________________________________________________________________
Employee Information
Total # of Owners: _______ Total # of employees (excluding owners):________ # Part-Time_______
Coverage Desired
Effective Date ___________________________________
Deductible: $250 $500 $1,000 $2,500
Building_______________________________
Business Personal Property ___________________________
Property of Others _______________________
Computer Equipment ____________________ Software ________________________
Law Library______________________
Building Glass____________________ Signs __________________________
Improvements & Betterments____________________________
Mechanical Breakdown ________________________________
Accounts Receivable __________________________________
Money & Securities (Inside/Outside) __________________________
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3. Ordinance & Law ________________________________
Spoilage Coverage _______________________________
Valuable Papers _________________________________
Utility Services – Direct Damage Coverage: _______ (Power Water Communications )
Utility Services – Time Element Coverage: ________ (Power Water Communications )
Backup of Sewer ____________
Include Property in the Open – Yard Storage Coverage? _________________________
General Liability________ ______________________
Medical Expenses ___________________________
Employee Dishonesty Coverage ____________________ Forgery & Alteration Coverage ________________
Stop Gap Coverage Needed? Yes No
Hired & Non-Owned Auto Coverage? Yes No
Employee Benefits Liability __________________________
Tenant Fire Legal Liability ___________________________
Miscellaneous Information
Does Business lease any employees to others? Yes No
Has any portion of the business been sold, acquired, or discontinued in the last 5 years? Yes No
Do employees use their own vehicles on company business? Yes No
If yes, does the business require employees to carry the state’s required liability limits or at least a
$300,000 limit? Yes No
What percentage of work is performed away from business premises? ____________
Has the business been active in or is it currently active in joint ventures? Yes No
Are any sporting or social events sponsored, including seminars, business or special events? Yes No
Has the business had any tax or credit liens, lawsuits, or judgements against the business in the past 5 years?
Yes No
Does the business have any operation or property owned, leased, or occupied that is not covered by this policy?
Yes No
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4. Does this business or would the business be willing to obtain evidence of insurance from others that perform
services (sub-contractors, janitorial services, snow removal services, etc)? Yes No
Has the business filed any bankruptcies or any company that the business owns filed any within the past 5 years?
Yes No
Does the business have past, present, or planned activity involving the storing, treating, discharging, or applying
hazardous materials? Yes No
Does the business do any installation and service or repair work? Yes No
Does the business have any sales or distribution of Imported Products? Yes No
Is the business considered non-profit as defined by IRS 501(c)? Yes No
Does the business carry Professional Liability Insurance? Yes No
Insurance Company ________________________________________
Policy # ________________________________
Expiration Date ________________________________
Limits _____________________________________
Current Policy Information
Name of Insurance Company ________________________________________________________
Current Expiration Date ______________________________________
Expiring Premium _________________________
# of consecutive years the business has had a BOP coverage in place without a lapse? _______
In the last 3 years, has any insurance company either declined to issue a policy, or cancelled, or failed to renew
existing coverage for the business?
Loss History
Date of Claim _____________________________
Type of Claim ___________________________________________
Amount _____________________ Settled? Yes No
Details_____________________________________________________________________________________
___________________________________________________________________________________________
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