Risk Questionnaire

General Information
Required - Mandatory - NEED TO COMPLETE INFORMATION
Contact's Full Name*
First Last
Full Mailing Address of Business Entity*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Name*
First Last
Business Name (if applicable)
Email*
Phone Number*

Property Coverage If Needed
Complete When Property Coverage Is Needed Or Leave Blank If Not Quoting
Physical Location Address (if multiple please provide SOV with list of all locations and below information per location):
Year Built
If Over 20 Years, Provide Year Roof, HVAC, Plumbing, And Electrical Updates
Total Square Footage Of Building
If Leased, Total Square Footage You Occupy
Type Of Construction (ie. Frame, Joisted Masonry, ETC…)
Sprinklers
- Yes
- No
Burglar
- Yes
- No
Number Of Stories
Total Estimate Value Building, Contents, Deductible
If leased, does the owner require you to carry betterments/improvements?
- Yes
- No
Amount

Auto Coverage If Needed
Complete If Auto Is Needed OR Leave Blank If Not Quoting
Number Of Autos
Physical Damage Needed
- Yes
- No
Physical Deductible Needed
- Yes
- No
Garage Location Of Vehicles

Need Full List Of Vehicle Information

Year	Make	Model	Full VIN #	Cost New(s) Of Each Vehicle

List Of All Drivers

Full Name	Address	DOB	License #	State Licensed

General Liability If Needed
Complete If GL Is Needed Or Leave Blank If Not Quoting
Need Estimated Total Sales/Revenue
If Contractor Need Payrolls
Do you need hired and non owned auto?
- Yes
- No
Limit Per Occurrence Your Required To Carry (1M, 2M, ETC…)
Will liquor be sold?
- Yes
- No
Liquor Percentage Of Sales Receipts
Do you want optional data breach protection?
- Yes
- No
If dealing with subs, tenants, ETC... Do you require them to carry comparable GL limits and listing you as additional insured and obtain certificates of insurance?
- Yes
- No

Workers' Compensation If Needed
Complete If WC Is Needed Or Leave Blank If Not Quoting
Total Annual Estimated Payrolls By State By Class
Full-time Employees
Part-time
Federal ID # Required In Order To Quote Workers Compensation
FIEN #
Life, Health, Employee Benefits, Home/Auto/Personal Umbrella, Professional

Comments - Miscellaneous
This Section Is For Anything Other Than What Was Asked Previously And Anything That Will Help UW
Additional Comments
Coverage will not be bound or changed until confirmed by a licensed agent.
This field is for validation purposes and should be left unchanged.
This field is for validation purposes and should be left unchanged.

Preliminary Risk Questionnaire for Businesses