Fact Find Form

1 General Information

2 Liability Information

3 Business Auto Information

4 Workers Compensation Information

5 Property Information

General Information
Name*
First Last
Email*
Referred By
Business Name
Business Type
- Individual
- Incorporated
Mailing Address
Street Address Address Line 2 City State ZIP Code
Phone
Work
Home
Cell
Other
Fax
Premises Address
Street Address Address Line 2 City State ZIP Code
Owner or Tenant?
- Owner
- Tenant
Years in Business
Nature / Description of Business
Coverages Interested In
- General Liability
- Commercial Auto
- Group Health / Life
- Property
- Tools / Equipment
- Workers Compensation
- Umbrella
Currently Insured?
- Yes
- No
Current Insurance - General Liabilty*
Insurance Company Effective Date Policy #
Current Insurance - Commercial Auto*
Insurance Company Effective Date Policy #
Current Insurance - Health/Life*
Insurance Company Effective Date Policy #
Current Insurance - Property*
Insurance Company Effective Date Policy #
Current Insurance - Tools / Equipment*
Insurance Company Effective Date Policy #
Current Insurance - Workers Comp*
Insurance Company Effective Date Policy #
Current Insurance - Workers Comp*
Insurance Company Effective Date Policy #
Current Insurance - Umbrella*
Insurance Company Effective Date Policy #
List Any Claims in the Last 5 years:
Claim Date Description Amount Paid
Federal Tax ID#

Liability Information
Limits Needed (if known)
General Aggregate
Products/Completed Operations Aggregate
Personal & Advertising Injury
Each Occurrence
Fire Damage
Medical Expense
Number of Owners
Number of Employees
Annual Gross Sales/Receipts (estimage for the coming year)
Annual Gross Payroll (excluding owners)
For Contractors Only:
Annual Payment to Insured Contractors
Annual Payment to Un-Insured Contractors
Does your Landlord or anyone else need a certificate of Liability Insurance?
- Yes
- No
Name
Address
Street Address Address Line 2 City State ZIP Code
Phone
Fax
Interest:
- Landlord
- Other
Other - Please explain*
Does this person or company need to be named as "additional insured"?
- Yes
- No
Please list any/all additional parties:

Workers Compensation Information
Federal Tax ID#
Have you had Workers Compensation before?
- Yes
- No
Do you currently have Workers Compensation?
- Yes
- No
If so, what states?*
Do you wish to cover owners of the business should they become injured on the job??
- Yes
- No
List Business Owners below:
Name Title
List your gross annual payroll below, grouped by job classification (i.e.: clerical, sales, driver, etc.)
Classification or Description # of Employees Total Annual Payroll

Make	Model	Year	Cost New	Full Coverage?	VIN#	# of Rear Axles	Annual Mileage

Name	Date of Birth	Drivers License #	Drive which vehicle?

General Information

Claim Date	Description	Amount Paid

Name	Title

Classification or Description	# of Employees	Total Annual Payroll

Description	Replacement Value	Deductable Preferred