Commercial Insurance Questionnaire

Your Contact Info

This is the primary contact for the business.

Referral Source (how did you hear about us?)

Full Name *

Title (e.g., Owner, President)

Cell Phone *

Work Phone

Email *

Home Address

What Are You Looking to Cover?

Choose one to continue.

Commercial Lines Business property, liability, auto, workers' comp & more Personal Lines Personal auto, home & other individual coverage

Business Information

Tell us about the business we're insuring.

Business Name *

DBA (if different)

Website

Business Address

Own or Lease Property?

Own Lease

Entity Type

EIN

Date Business Started

Gross Annual Revenue

NAICS Code / Description of Operations

What does the business do day to day? Include NAICS/SIC code if known.

Ownership

Add every owner and their percentage of the business.

Payroll & Staffing

# of W-2 Employees

Total Annual Payroll

Current Insurance

List All Current Policies

Expiration Date(s)

Any Past Losses / Claims

Commercial Coverage Needed

Check everything you'd like us to quote.

Anything Else?

Additional Notes

Completed With (agent name, office use)

Your answers go directly to Insurance Catalysts and are used only to shop your coverage. We will never ask for your Social Security number through this form.

✓

Thank you!

Your information has been sent to Insurance Catalysts. We'll review it and reach out shortly.

Commercial Insurance Questionnaire

Your Contact Info

What Are You Looking to Cover?

Personal Lines Intake

Business Information

Ownership

Payroll & Staffing

Current Insurance

Commercial Coverage Needed

Anything Else?

Thank you!