CL Questionnaire CL Questionnaire Long Form CL Questionnaire Step 1 of 13 7% Company Name* Please include business entity (Inc, LLC, Partnership, Sole Proprietor, etc.) Do you have a Doing Business As Name or Trading As Name (DBA or TA)* Yes No Doing Business As Name* DBA Phone*Email* Website Federal Employee Identification Number (FEIN or EIN) Who Is Completing This Form First Last Title at Company Please List all Owners of the Business & the Percentage They OwnWhat Is The Expiration Date the Current Policies or What Date Do You Want Coverage To Start?*If you are purchasing an exsisting business or property, please provide the expected close date. If you are starting a new business, please provide the date you expect the business to open or that you want coverage in place. Extra space is provided so you can give additional details if needed. Please include a need by date.Description Of Your Business*Please provide us a description of your business. The more detail you provide, the better rates and coverage we will be able to provide you.How did you find our agency?*For internal use, how do you know the client? What is your relationship with them?Please describe your experience in this field or a related field. The more detail we have the better rates we can get. If this is a new business, how much management experience do you or other owners have in this field?Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is The Location Address Different From the Mailing Address?* Yes No Location Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is There Second Location?* Yes No Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is There A Third Location?* Yes No Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is There A Fourth Location?* Yes No Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are There Any Additional Locations?* Yes No Please List Additional LocationsDate or Year Your Business Started* Estimated Annual Sales/Revenue - If unsure, please give best estimate.*Do you have employees or plan to hire any in the near future?* Yes No List# of Full-Time# of Part-Time Do you provide Health, Vision, Dental, Disability, Life Insurance or any other benefits to your employees?* Yes No Would you like to review your coverage with one of our specialists?* Yes No Would you like to discuss adding any of these coverages with one of our specialists?* Yes No Do you use sub-contractors? Yes No How much do you pay your sub-contractors total for the year?Do you get insurance certificates from you sub-contractors? Yes No Total Payroll (Not including Owners)*If no employees, please put 0.Do you want or need a Liability Insurance?* Yes No Do you currently have Liability Insurance?* Yes No Who is your current carrier for liability and property insurance? Current Annual Premium General Liability Per Occurrence LimitGeneral Liability Aggregate LimitDamaged to Rented Premises LimitMedical Payments LimitDo you have Professional or Errors & Ommissions Liability Insurance? Yes No An additional supplemental application is usually required to get a proposal.Would you like a proposal? Yes No An additional supplemental application is usually required to get a proposal. We will be in touch.Hours of Operation Are you a restaurant, bar, or do you serve alcohol? Yes No Do you serve, provide, or allow alcohol at your business? Yes No Estimated Annual Food & Alcohol Combined SalesEstimated Annual Alcohol SalesDo you have an Ansul System covering all cooking surfaces? Yes No Do you have an contract with a company to have hoods & ducts cleaned at least every 6 months? Yes No Do servers and bartenders take alcohol safety training? (Like TIPS) Yes No What type of liquor serving training program do you use? Do you currently have liquor liability insurance? Yes No Current Liquor Liability Per Occurrence LimitCurrent Liquor Liability Aggregate LimitCurrent premium?Additional Comments on LiabilityDo you want or need property coverage?* Yes No This can including building coverage, contents, business personal property, or tools and equipment. Do you want or need property coverage?* Yes No This can including building coverage, contents, business personal property, or tools and equipment. Do you own the building?* Yes No Is it owned in the same name as your business? Yes No Building Owner Please include business entity (Inc, LLC, Partnership, Sole Proprietor, etc.)Building & Personal Property LimitsBuilding LimitBusiness Personal LimitBusiness Income Limit If more than one location, hit the + to add another row. Please list coverages in the same order you listed them on the first page. Building InformationYear BuiltSquare FootageNumber of Units/Tenants% of the building occupied by your business If more than one location, hit the + to add another row. Please list coverages in the same order you listed them on the first page. Updates to BuildingsRoofElectricPlumbingHeating Please list last time the following items were updated on each building. If more than one location, hit the + to add another row. Please list coverages in the same order you listed them on the first page. Deductible$500$1,000$2,500$5,000If you take equipment of site, rent equipment, or have large machinery, please provide information below.You can attach a list of the equipment and limits at the end of this form or email separate.Additional Property Coverages/CommentsDo you want a proposal on Workers Compensation Insurance?* Yes No Workers compensation is require by law if you have any employees. Do you want a proposal on Workers Compensation Insurance?* Yes No Workers compensation is require by law if you have any employees. Do you currently have a Workers Compensation policy?* Yes No Who is your current workers compensation company? What is your current annual premium? Description of what employees will be doingCurrent Classifications & Payroll EstimatesClass CodeClass DescriptionRateAnnual Payroll Estimate Hit the "+" symbol to add additional classifications.Employers Liability Limit$100,000/$500,000/$100,000$500,000/$500,000/$500,000$1,000,000/$1,000,000/$1,000,000Please check any that apply Currently Lease Employees FROM other company. Have the safety credit provided by the state of Pennsylvania Currently Lease Employees TO others. Please list any other coverages or notes you would like us to know.Do you want a proposal on commercial auto insurance?* Yes No If you own any vehicles in the business name or use them primarily for business use, you should have a business auto policy. Do you want a proposal on commercial auto insurance?* Yes No If you own any vehicles in the business name or use them primarily for business use, you should have a business auto policy. Do You Currently Have a Business/Commercial Auto Policy?* Yes No Current Insurance Company Current Annual Premium Liability Limit Please enter your liability limit. If it is a split limit, please put per person limit / per accident limit / property damage limit. Ex. $100,000 / $300,000 / $100,000Is Hired & Non-Owned Liability Coverage Included? Yes No Do you have uninsured and underinsured motorist coverage? Yes No Uninsured Motorist Liability Limit Stacking Option Stacked Unstacked Unknown Are Underinsured Limits the same? Yes No Underinsured Motorist Liability Limit Stacking Option Stacked Unstacked Unknown First Party BenefitsMedical ExpenseWork LossFuneral ExpenseAccidental Death Do You Have Extraordinary Medical Benefits? Yes No Extraordinary Medical Benefits Limit? VehiclesYearMakeModelVINComp & Collision (Y or N)Used for Business, Pleasure, or Both? Hit the "+" symbol to add additional vehicles. DriversNameDate of BirthDriver's license NumberCDL (Y or N)Married (Y or N) Hit the "+" symbol to add additional drivers. Please list all drivers that regularly drive business vehicles.Towing & Labor Limit If you do not have this coverage, type None.Rental Reimbursement If you do not have this coverage, type None.Do any of the drivers use the vehicles for personal use and NOT have a personal auto policy? Yes No If any of the drivers do not have a personal auto policy, we will need to add coverages so they have the extra coverages that are included with personal auto, but not with commercial auto.Please list owners/drivers that do not have a personal auto policy? Please list any other coverages or notes you would like us to know.Do you want a proposal for a commercial umbrella policy?* Yes No Do you want a proposal for a commercial umbrella policy?* Yes No Do you currently have an umbrella policy?* Yes No Current Insurance Company Current Annual Premium Current or Requested Limit$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000More than $5,000,000Please list any other coverages or notes you would like us to know.Are you interested in Directors & Officer's, Employment Practices Liability, Cyber Liability, Bonding, Health Insurance, Life Insurance, Personal Home/Auto Insurance or any other type of insurance?* Yes No Are you interested in Directors & Officer's, Employment Practices Liability, Cyber Liability, Bonding, Health Insurance, Life Insurance, Personal Home/Auto Insurance or any other type of insurance?* Yes No Please provide any additional information or comments about Directors & Officer's, Employment Practices Liability, Cyber Liability, Bonding, Health Insurance, Life Insurance, Personal Home/Auto or any other type of insurance. Who do you want this form sent to?* Do Not Know? Leslie Humes (A-J) Sue Cole (K-Z) Mike McGroarty Jr Megan McGroarty Rick George Justin Safran Adrien King Mike Hanley Justin Neal Please select as many people as you want. CL Account Managers are divide accounts alphabetically by company name. If you are not sure who to send it to, please hit "Do Not Know?" and it will be distributed by our staff.What date do you need the proposals by? MM slash DD slash YYYY Depending on the size of the account, please set proper expectations with the insured. Thank You for taking the time to complete our questionnaire. Please put any additional comments below.Please Upload Copies of Policies/Certificate Requests/Contracts/or Other Pertinent Information. Drop files here or Select files Max. file size: 98 MB.
