WC/CGL/BOP Insurance Intake Questionnaire - Almeida and Carlson Insurance Agency

In order to provide an accurate rating for an insurance quote, please answer the following questions (mark “N/A” if not applicable):

Proposed effective date of coverage:

Do you have an existing policy?(Required)

If so, how long have you had it?

Please provide us a copy of the policy.

Business Name:(Required)

Primary Contact / Applicant Name:(Required)

First Last

Phone(Required)

Email(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Location (If Different)

Street Address Address Line 2 City State ZIP Code

Is the location rented/leased space?

Website

Year in business under current ownership:

Years of total experience the owner in this field:

Executive officer name & percentage of ownership:

Corporation, LLC, LLP, Sole Proprietor, Partnership, Non‐Profit, or Other:

Federal ID #:

What type of business do you do?

Be as specific as possible regarding the type of business/include typical daily tasks/responsibilities.

Liability coverage only or include coverage for personal property, equipment, building coverage, etc?

Estimate of gross receipts for the upcoming year:

Estimate of payroll for the upcoming year:

How many employees:

Any part time or seasonal employees?

Do you use the services of subcontractors, owner‐operators, and/or independent contractors?

Do employees travel outside of MA?

If yes, what percentage?

Any previous WC or GL losses (claims history)?

For sole proprietor/partner ONLY – would you like to include Workers Compensation coverage for yourself? *If you are excluded and experience an injury on the job, you will not be covered by Workers Compensation. Please consider the pros and cons when deciding whether you wish to include or exclude yourself from your Workers Compensation policy.

Please choose one:

Exclude myself from my WC Policy

Do NOT exclude myself from my WC Policy

*Please be sure to answer all applicable questions to help ensure accurate rating. If you have a current policy and would provide us with a copy it will help expedite the quoting process. Thank you for choosing Almeida & Carlson Insurance Agency for your insurance needs!

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