Policy Questionnaire Template

Policy Questionnaire Template

Parties

Client Name:

Service Provider Name:

Recitals

WHEREAS, Client seeks to procure, evaluate, or renew insurance policies and related risk transfer instruments for its business operations; and

WHEREAS, Service Provider is engaged to collect, analyze, and report information necessary to recommend policy types, coverage limits, and underwriting submissions; and

WHEREAS, the parties desire to set forth the scope of engagement, payment, confidentiality obligations, and accurate representations relating to the information provided in this questionnaire.

Business Information

Corporation LLC Partnership Sole Proprietor Nonprofit

Operations & Revenue

Current Insurance Coverage

Indicate existing coverages and current limits (if applicable):

General Liability Professional Liability Workers' Compensation Cyber Liability

Property Insurance Directors & Officers Umbrella/Excess Other

Claims History

Any claims, suits, incidents, or notices that might give rise to a claim in the past five (5) years? Yes No

Risk Management & Loss Control

Employee training provided:

Cybersecurity & Data Privacy

Does the organization store or process personal or payment data? Yes No

Incident response plan in place? Yes No

Date of most recent penetration test / security assessment:

Employment Practices

Background checks conducted on employees? Yes No

Harassment and discrimination training frequency:

Scope of Work

Payment Terms

Total Fee: $

Late fee for overdue invoices (percentage): % per month on outstanding balance

Term and Termination

Agreement Start Date:

Agreement End Date (if applicable):

Either party may terminate upon written notice delivered at least days prior to the effective termination date. Termination for material breach may be immediate in cases where remedial action is not timely taken.

Confidentiality

Each party acknowledges that information exchanged in connection with this questionnaire and the scope of work may include proprietary, privileged, or otherwise confidential business information (Confidential Information). Each party agrees to: (a) use Confidential Information solely for purposes of fulfilling obligations under this agreement; (b) restrict disclosure to those employees, agents, or contractors who have a need to know and who are bound by confidentiality obligations at least as protective as those herein; and (c) not disclose Confidential Information to any third party except as required by law or with prior written consent. Confidentiality obligations shall survive termination of the engagement for a period of three (3) years, except for trade secrets which shall remain protected for as long as they qualify as trade secret under applicable law.

Governing Law

This agreement and any dispute arising out of or relating to it shall be governed by and construed in accordance with the substantive laws of the chosen jurisdiction. The parties hereby submit to the exclusive jurisdiction of the courts of the chosen jurisdiction for resolution of disputes.

Entire Agreement

This document, including the completed questionnaire responses, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous agreements, proposals, representations, and understandings, whether written or oral. Any amendment must be in writing and signed by authorized representatives of both parties.

Additional Information

Certifications & Attestations

The undersigned certifies that, to the best of their knowledge, the information provided in this questionnaire and any attachments is true, complete, and presented in good faith. The undersigned acknowledges that material misrepresentation, omission, or concealment of facts may affect coverage, premiums, or lead to rescission of a policy. The undersigned further authorizes Service Provider to share this information with insurers and brokers as necessary to obtain coverage and quotes.

I certify that the information provided is accurate and complete.

Sign Now