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  • General Liability Questionnaire

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    Kenny LeBlanc
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    QUESTIONNAIRE: ________________________________ __________________________ Years Exp in Business:________ Prior Insurance Co. _____________________ # of years Insured: ___________________ Losses In Last 3 years ___________________ Type of Business: ______________________________................_____________________ Deductible Amount: Hours of Operation:._____________________ Annual Sales:._______________ ____________________ Year of Construction:. ___________________ County: _____________

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    QUESTIONNAIRE: ________________________________ __________________________ Years Exp in Business:________ Prior Insurance Co. _____________________ # of years Insured: ___________________ Losses In Last 3 years ___________________ Type of Business: ______________________________................_____________________ Deductible Amount: Hours of Operation:._____________________ Annual Sales:._______________ ____________________ Year of Construction:. ___________________ County: _____________

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    43 views2 pages

    General Liability Questionnaire

    Uploaded by

    Kenny LeBlanc
    QUESTIONNAIRE: ________________________________ __________________________ Years Exp in Business:________ Prior Insurance Co. _____________________ # of years Insured: ___________________ Losses In Last 3 years ___________________ Type of Business: ______________________________................_____________________ Deductible Amount: Hours of Operation:._____________________ Annual Sales:._______________ ____________________ Year of Construction:. ___________________ County: _____________

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    GENERAL LIABILITY QUESTIONNAIRE

    Risk Is: June 1, 2011

    __ Partnership __ Corporation__ Sole Proprietor__ Joint Venture__ S Corporation__ Other

    Name: (Individual) Last:_____________________ First: ____________________

    Fed # or Social # : ________________________________________

    D.B.A.: __________________________________________

    Address: ________________________________________

    City: ___________________________________________ Zip: ________________

    Phone No. ____________________ Cell #: ___________________ Fax #: ________________

    Email: ________________________ Web Site Address: ____________________________

    Number of Years in Business ___________________ Years Exp in Business:________

    Prior Insurance Co. _____________________ # of years Insured:___________

    Losses In Last 3 Years ________________________

    Type of Business _____________________________________________________

    Deductible Amount: __$250 __$500 __$1000

    Hours of Operation: ____________________________

    Annual Sales: _____________________________________

    Own Building or Lease or Work from Home:___________________________

    Amount of Building Coverage: ______________________

    Contents Coverage: ________________________________

    Exterior Glass Area: _______________________________

    Total Area of the Building: __________________________

    Area Occupied: ___________________________________

    Business on the right side: ______________________ Left: _______________________


    Sprinklers: __Yes __No Alarm Type: ____________________

    Year of Construction: ____________________ County: ______________________

    Has it been renovated? __Year? __No. of Stories

    Sign Coverage: ___________________________________

    Accounts Receivable: ______________________________

    Valuable Papers: _________________________ Computer Coverage: ______________

    Crime Coverages:
    Money & Security More than $5,000? _________________

    Employee at all locations _________________

    # of Part Time: __________________ # of Full Time: ______________________

    Liability Limit: __500,000 __1,000,000 __2,000,000

    Fire Legal Liability: __75,000 __150,000 __250,000 __500,000


    __1,000,000

    Commercial Auto Coverages? See Commercial Auto Questionnaire

    During Last 3 years any coverage cancelled, non renewed, declined or place in non
    standard markets?

    Any Athletic Teams Sponsored?

    Workers Comp which Company: _________________________________

    Copy of current Declaration page?

    Date to Start Policy:

    Additional Insured? _______________________________________________________

    Additional Information: ____________________________________________________

    _______________________________________________________________________
    _

    An agent will contact you shortly.

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