Coshare commercial general liability and business owner's policy questionnaire

Business Name:

Primary Contact Name:

Business Address or Primary Location: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Any Additional Locations?

Yes
No

If yes, please provide addresses for all additional locations:

Date Business was Established:

FEIN Tax ID Number:

Business Entity Type (S Corp, LLC, Sole Proprietor, etc.):

Primary Contact Telephone Number:

Primary Contact Email Address: Verify Primary Contact Email Address:

Website Address:

Please specifically describe the business you are engaged in:

Plesae provide a full list of the products and/or services that your business provides (please be specific):

Gross Annual Sales Revenue (please estimate if necessary):

Total W-2 Reported Payroll:

Desired Effective Date of Coverage:

Do you own more than 50% in any other business?

Yes
No

If yes, please describe the other business and tell us whether you have coverage for that other business:

Do you work out of your home or an office?

If you work out of an office, do you own your office building?

Yes
No

If you own the office building what is the replacement value to insure?

Square footage of office space?

What year was the home or office building built?

If the home or office is older than 25 years has the plumbing, HVAC and/or electrical been updated? Please explain when and what was updated:

What kind of structure is your home or office building (frame, brick, flat roof, etc.)?

Number of stories?

Does the building have a sprinkler?

Yes
No

Does the building have an alarm system?

Yes
No

Do you have any sales through the internet with no customer contact?

Yes
No

Amount of insurance needed to cover the Business Personal Property or Inventory:

Is the Business Personal Property and Inventory all in one location?

Yes
No

Any property of others that you would like to insure?

Yes
No

If yes, please describe (be specific):

Have you had any insurance losses (claims) in the past 5 years?

Yes
No

If yes, please describe (be specific):

Does the proposed insured have a commercial auto policy in-force?

Yes
No

How many owners, directors, employees and/or contractors regularly (3 or more times per week) use their personal autos for business?

What is the maximum area of operation?

Local (< or = 50 miles)
Intermediate (51 - 200 miles)
Long Distance (> 200 miles)

Does driving involve any of the following (please check all that apply)

Time Constraints
Routine Errands
Student or Youth Transport
Outside Sales
Other Deliveries

Please indicate the control measures in place:

Employees carry Personal Auto Liability Coverage of $100k/$300k/$50k split or $300k single limit
Drivers MVRs are on file and checked annually by insured
Age and driving experience considered in allowing use of personal vehicles

Do the insured or insured's employees regularly use hired or rental vehicles in the course of conducting business?

Yes
No

Additional Coverage and extensions (Coverage to consider - some of these come automatically but please indicate areas of concern or areas that you want additional coverage)