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Commercial Lines New Business Questionaire

(* Required Field)

Contact Name:

Disclaimer: No insurance coverage or policy change will take effect until a Hoffman Group associate advises you by phone or through written communication that coverage has been placed. If you need immediate service, please call us at (800) 826-4006.

NOTE: In an effort to better serve you, completion of all areas indicated with an * is required.

Business Name:

Referred By:

Phone:

Fax:

E-mail:


Received any other quotations?

If so, from whom?

Target Price?

Date Need Proposal

Location Address

Any other locations?

Mailing Address (if different)

Entity

If other, please specify

Years in Business

Type of Operations

Specific Business Operations

Current Insurance Company

Losses in last 3 years

Property

Location 1

Building Limit
Contents Limit
Business Income Limit
Construction Type
Square Footage
Deductible

Location 2

Building Limit
Contents Limit
Business Income Limit
Construction Type
Square Footage
Deductible

General Liability

Limits		$500,000 each occurrence $1,000,000 each occurrence annual
Limits		$1,000,000 each occurrence $2,000,000 each occurrence annual

Annual Sales
Annual Payroll
Number of Employees

Automobile Information:

Driver 1
Name
SS#
Vehicle 1
Make/Model
Year
Garaging Zip Code
Use
Deductibles
Cost New
Comp. Ded.
Collision Ded.

Driver 2
Name
SS#
Vehicle 1
Make/Model
Year
Garaging Zip Code
Use
Deductibles
Cost New
Comp. Ded.
Collision Ded.

Inland Marine

Contractor's Equipment Value		Tools Value
Installation Floater		Other Value

Computers

Hardware Value		Software Value
Extra Expense Value		Other Value

Umbrella

Limits

2 Berea Commons, Suite 10 Berea, Ohio 44017	5329 N. Abbe Rd. Suite 4A Elyria, Ohio 44035	5000 Foote Road Medina, Ohio 44256
	1.800.826.4006