A Freeman Insurance Agency, LLC - General Commercial Survey Quote Form

Quote Needed By:

Date

Describe Business Activity:

APPLICANT

Legal Entity Name (Name of Business):

Doing Business As (DBA):

(*Optional, and typically only used when the legal entity is a sole proprietor. Example- John Smith DBA Smith Construction)

Business Entity Type:

Describe Business Entity Type

Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Contact Person:

Cell Phone:

Business Phone:

Email:

Federal Employers Tax ID # (FEIN):

*9 digit number

SS#:

Website:

Date Business Started:

Date

If new, provide details of Business Experience:

Any bankruptcies, tax or credit liens against the applicant in the past 5 years:

Verbal Disclosure:

Several carriers require the OWNER'S SS# for accurate rating. In connection with this application for insurance, we may review your credit report to obtain and use an insurance loss evaluation score which is based on credit related characteristics, we will use a third party in connection with the development of your insurance loss evaluation score. Entry of the SS# on this survey confirms the owner's acceptance to proceed in cases where the info is needed.

PROPERTY: This section only applies if a physical bricks & mortar location is used for business

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Inside city limits?

Distant (In Feet) from fire hydrant?

Distant (In Miles) from Fire Department?

Protect. Class:

For Agency Use Only

Applicant is

Triple Net Lease?

If you insure the building, in whose name is the Building deeded?

Year Built:

Rennovation dates if over 25 years

Roof:

Plumbing:

Electrical:

Heating:

Number of stories:

Construction type:

Total Building Square Feet:

Your Square Feet:

Percentage Vacant:

Sprinklered Percentage:

List other Building occupants:

Current Building Coverage:

Current Deductible:

Is there a basement?

Business Personal Property coverage amount needed ($5000 Included automatically):

Tenants’ betterments & improvements needed:

Alarm Type:

Alarm Company:

General Liability -

Limit needed:

Other:

Number of Owners:

Number of W2 employees (Do Not Include Owners):

Full Time:

Part Time:

Annual Payroll (True W-2 Employees only. Do not include Owners):

Number of 1099 Sub Contractors:

Amount paid to 1099 Sub Contractors over the next 12 months:

Gross Annual Receipts:

IF there are multiple revenue-generating business activities:

Describe The Business Activity & % of Revenue Generated From Each Activity:

Do you currently carry Directors & Officers Liability?

Benefits Questions

Do you offer Employee benefits?

Do you offer 401(K) plans to Employees?

If yes, total 401(K) plan assets

401(K) plan name:

LOSS HISTORY STATEMENT:

I, *, have owned and operated * for the past * years. To the best of my knowledge the CLAIMS HISTORY for my company is as follows:

IF any known losses, please list below:

Rows	Name	Description/Type of Loss	Approx. Amount Paid
1
2
3

I attest that, to the best of my knowledge, the information above is correct.

I understand that premiums quoted for my business will be based on the claims history information. I have provided above and that premiums may change based on a “verified loss run” from my current insurance carrier(s).

Applicant Signature

Date