Commercial Lines Customer Information Questionnaire

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

Company Name(Required)

FEIN(Required)

Website(Required)

Years in Business(Required)

Revenues(Required)

# of EEs(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Is physical address same as mailing address?(Required)

Yes

No

Physical Address(Required)

Street Address Address Line 2 City State ZIP Code

Contact(Required)

Phone(Required)

Email(Required)

Nature of Operations (Detailed)(Required)

What type(s) of coverages are you interested in:(Required)

General Liability

Property

Auto

WC

Inland Marine

Umbrella

EPLI

Cyber

Employee Benefits

General Liability

Annual Payroll(Required)

Additional Insured(Required)

Yes

No

Provide more detail

Waivers of Subrogation Required(Required)

Yes

No

Provide more detail

Do you use subcontracted work?(Required)

Yes

No

% of Work Subcontracted(Required)

Type of Work(Required)

Property

Year Built(Required)

Square Feet(Required)

# of Stories

Construction Type(Required)

Roof Material(Required)

Occupancy(Required)

Ownership(Required)

Owned

Leased

In which year was the following last replaced?

Roof(Required)

Electric(Required)

Plumbing(Required)

HVAC(Required)

Building Cost(Required)

Contents Value(Required)

Fire/Burglar Alarm Present?(Required)

Yes

No

Are you interested in Business Income/Extra Expense Coverage?(Required)

Yes

No

Mortgagee(Required)

Auto

Provide a vehicle list:(Required)

Upload a file with vehicle list

Manually fill out a vehicle list

Upload vehicle list:(Required)

Max. file size: 512 MB.

Vehicle List

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.

Provide a driver list:(Required)

Upload a file with driver list

Manually fill out a driver list

Upload driver list:(Required)

Max. file size: 512 MB.

Driver List

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.

Do any employees take company vehicles home?(Required)

Yes

No

Do any family members use company vehicles?(Required)

Yes

No

Do you have a safety program?(Required)

Yes

No

Radius of vehicles? (in miles, one way)(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.

Do you use subcontractor(s) or 1099s?(Required)

Yes

No

Why and how many?(Required)

Do you perform work above 15ft?(Required)

Yes

No

Maximum feet?(Required)

Do you have a written safety program?(Required)

Yes

No

Drug-free program?(Required)

Yes

No

Does any of the owners of this business own 50% of more of any other business?(Required)

Yes

No

Inland Marine

Provide a schedule of equipment:(Required)

Upload a schedule of equipment file

Manually fill out a schedule of equipment

Schedule of equipment upload(Required)

Max. file size: 512 MB.

Untitled

Row ID	Year	Make	Model	Serial #	Value	Actions

There are no Entries.

Rented/Leased Equipment Value Limit(Required)

Miscellaneous/Unscheduled Tools – Under $1,000 – Value(Required)

Employee Benefits

# Enrolled(Required)

Employer Contributions(Required)

What does your current wellness program consist of (include products/plan types, incentive programs, HSA, FSA, etc)?(Required)

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

Yes

No

Current Agent(Required)

How are you handling open enrollment, new hires, terms, billing questions?(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)

I AGREE

Comments

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