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Commercial Account Survey

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Company Name *

Business Address *

Address Line 2

City, State Zip *

Type of Business *

Breif description of work performed *

Owners Name *

Owners Phone *

Number of Locations *

Year Established *

Does the Business "Own" Vehicles *

YES NO

# of Vehicles

# of Drivers

Current Coverage:

Current Carrier *

General Liability Limit *

$500 K $1000 K $2000

Business Personal Property Limit $ *

Deductible $ *

# of Losses in last 5 years *

0 1 2 3

Rating Information:

Gross Revenue $ *

Number of Employees *

Annual Payroll $ *

Building Insurance:

Ground Floor Square Feet

# of Stories

Construction

Frame Joisted Mas. Mas. Non-Comb.

Current Building Limit $

Coinsurance Limit %

50 80 90 100

Deductible $

Year Built

Basement

Yes No

Burglar Alarm

Yes No

Fire Alarm

Yes No

Optional Coverages:

Stop Gap Liability

Yes No

Hired/Non Owned Autos

Yes No

Employee Benefits Liability

Yes No

Employer Practices Liability

Yes No

Professional Liability

Yes No

Directors and Officers Liability

Yes No

Sexual Misconduct Liability

Yes No

Liquor Liability

Yes No

Garage Keepers Liability

Yes No

Most Recent Year for Building Update:

Electric

Plumbing

HVAC

Roof

( * Required Field )