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Commercial Lines Customer Information Questionnaire

Commercial Lines Customer Information Questionnaire

Step 1 of 8

12%

Let’s get started! Please tell us a little bit about yourself.

Mailing Address(Required)
Is physical address same as mailing address?(Required)
Physical Address(Required)
What type(s) of coverages are you interested in:(Required)

General Liability

Additional Insured(Required)
Waivers of Subrogation Required(Required)
Do you use subcontracted work?(Required)

Property

Ownership(Required)

In which year was the following last replaced?

Fire/Burglar Alarm Present?(Required)
Are you interested in Business Income/Extra Expense Coverage?(Required)

Auto

Provide a vehicle list:(Required)
Max. file size: 512 MB.
Row ID Vehicle Year Vehicle Make Vehicle Model Vehicle Identification Number (VIN) Usage (Miles driven per year) What is the vehicle’s primary use Cost New GVW Actions
                 
There are no Entries.

Maximum number of entries reached.

Provide a driver list:(Required)
Max. file size: 512 MB.
Row ID Driver’s Name Driver’s License Number Driver’s Date of Birth Driver’s License State Driver’s License Status Actions
           
There are no Entries.

Maximum number of entries reached.

Do any employees take company vehicles home?(Required)
Do any family members use company vehicles?(Required)
Do you have a safety program?(Required)

WC

Provide Workers’ Compensation exposures:

Example: | Outside Sales | 4 | $100,000
Row ID Position # of employees Estimated Total Annual Payroll Actions
       
There are no Entries.

Maximum number of entries reached.

Do you use subcontractor(s) or 1099s?(Required)
Do you perform work above 15ft?(Required)
Do you have a written safety program?(Required)
Drug-free program?(Required)
Does any of the owners of this business own 50% of more of any other business?(Required)

Inland Marine

Provide a schedule of equipment:(Required)
Max. file size: 512 MB.
Row ID Year Make Model Serial # Value Actions
           
There are no Entries.

Maximum number of entries reached.

Employee Benefits

Would you be interested in offering Ancillary Products? (like Accident, Critical Illness, Hospital Indemnity, Disability, and Legal Protection)(Required)

Conclusion

I understand that any submission via this website does not constitute as an agreement to bind insurance coverage and the information must be confirmed by a PGI team member via phone or email.(Required)
This field is for validation purposes and should be left unchanged.

      

    Tampa Bay

      5215 West Laurel St
    Suite 100
    Tampa, FL 33607
      813.288.8270     813.885.4311

    South Florida

      4880 Donald Ross Rd.
    Suite 110
    Palm Beach Gardens, FL 33418
      561.578.6667    813.885.4311

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Not Your Average Insurance Agency™
Call Us: 844-631-4901
Email Us: info@primegroupins.com


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