CL Questionnaire CL Questionnaire Long Form CL Questionnaire Step 1 of 9 11% 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 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.Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is There Second Location?* Yes No Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is There A Third Location?* Yes No Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is There A Fourth Location?* Yes No Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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* If this is a new business, how much management experience do you or other owners have in this field? Please describe your experience. The more detail we have the better rates we can get.Estimated Annual Sales/RevenueTotal Payroll (Not including Owners)How many owners or partners are there?* 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.Do you serve, provide, or allow alcohol at your business? Yes No Hours of Operation 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 training of training? 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 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. 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$5,000Additional 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 currently have a Workers Compensation policy? Yes No What is your current annual premium? Who is your current workers compensation company? Number of EmployeesDescription of what employees will be doingEstimated Annual Payroll Excluding OwnersCurrent 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. Current Annual Premium?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 currently have an 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 VehiclesYearMakeModelVINComprehensive DeductibleCollision DeductibleUsed for Business, Pleasure, or Both? Hit the "+" symbol to add additional vehicles. If you do not have comprehensive or collision coverage on a vehicle, enter None.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.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 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.
