CL Questionnaire

Long Form CL Questionnaire

Step 1 of 13

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 Own
What 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 State ZIP Code
Is The Location Address Different From the Mailing Address?*
- Yes
- No
Location Address
Street Address Address Line 2 City State ZIP Code
Is There Second Location?*
- Yes
- No
Address
Street Address Address Line 2 City State ZIP Code
Is There A Third Location?*
- Yes
- No
Address
Street Address Address Line 2 City State ZIP Code
Is There A Fourth Location?*
- Yes
- No
Address
Street Address Address Line 2 City State ZIP Code
Are There Any Additional Locations?*
- Yes
- No
Please List Additional Locations
Date 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 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 Limits
Building Limit Business Personal Limit Business 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 Information
Year Built Square Footage Number 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 Buildings
Roof Electric Plumbing Heating

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
If 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/Comments
Do 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 doing
Current Classifications & Payroll Estimates
Class Code Class Description Rate Annual Payroll Estimate

Hit the "+" symbol to add additional classifications.
Employers Liability Limit
Please 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 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
Please 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.

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Medical Expense	Work Loss	Funeral Expense	Accidental Death

Year	Make	Model	VIN	Comp & Collision (Y or N)	Used for Business, Pleasure, or Both?

Name	Date of Birth	Driver's license Number	CDL (Y or N)	Married (Y or N)

Year Built	Square Footage	Number of Units/Tenants	% of the building occupied by your business

# of Full-Time	# of Part-Time

Building Limit	Business Personal Limit	Business Income Limit

Roof	Electric	Plumbing	Heating

Class Code	Class Description	Rate	Annual Payroll Estimate

CL Questionnaire

CL Questionnaire

Step 1 of 13

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