Insurance Commercial Renewal Questionnaire

INSURANCE COMMERCIAL RENEWAL QUESTIONNAIRE

Applicant / Insured Information

Contact Person:    Title:    Phone:

Date of Formation/Incorporation:    Federal Tax ID / EIN:

Policy Details (Renewal)

Current Insurer:    Policy Number:

Policy Type(s): General Liability Property Auto Workers' Compensation Professional Liability Business Interruption

Coverage Limits:    Deductible:

Annual Premium (current):    Requested Premium (if known):

Policy Period: From to

Business Operations & Exposures

Annual Gross Receipts:    Number of Employees (full-time equivalents):

Do you subcontract work to others? Yes No    If yes, attach certificate of insurance and provide details below.

Property / Location Details

Location(s) to be insured (address and description):

Total Insurable Value - Buildings:    Contents / Business Personal Property:

Protective Safeguards (check all that apply): Sprinkler Central Station Alarm Fire Extinguishers Security Personnel

Automobile / Equipment

Number of Owned Vehicles:    Number of Hired/Non-Owned Vehicles:

Employment Practices & Workers' Compensation

Does the applicant have exposure to employee theft or fidelity concerns? Yes No

Total Payroll (last 12 months):    Highest paid individual compensation:

Claims History (Past 5 Years)

Have there been any claims or losses in the past five (5) years? Yes No

Prior Coverage, Cancellations & Non-RenewALS

Has any insurer cancelled or non-renewed your coverage in the last three years? Yes No

Risk Management / Loss Control

Have there been any significant changes to operations, premises, or exposures since the prior policy period? Yes No

Have any safety, loss prevention or training programs been implemented or modified since last policy? Yes No

Additional Insureds / Loss Payees / Mortgagees

Beneficiary / Payee Designation (if applicable)

Beneficiary/Payee Name:

Relationship to Insured:    Percentage of Proceeds:

Exclusions, Endorsements & Requested Changes

Documentation Checklist

Please indicate enclosed documentation: Photographs of premises/equipment Recent financial statements Copies of contracts/subcontracts Loss runs (past 5 years)

Declarations and Authorization

The undersigned authorized representative certifies, under penalty of civil and criminal liability for material misrepresentation, that the statements and facts set forth in this questionnaire are true, accurate and complete to the best of their knowledge. The undersigned understands that this questionnaire and any attachments will form a part of the policy application and may be relied upon by the insurer in underwriting and renewal decisions. Any material misrepresentation, omission or failure to disclose a material fact may result in denial of coverage or rescission of the policy.

The applicant authorizes the insurer to obtain claim and loss information from prior insurers, claims databases, and other sources necessary to evaluate the renewal application. The applicant further agrees to notify the insurer of any material change in operations or exposures prior to the effective date of any renewal policy.

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