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Home » Our Forms » Insurance Questionnaire for Main Street Organizations

Every main street organization is different. Consider filling out our form and we’ll get back to you soon.

Get the insurance your main street organization needs.

Please complete the form to your best ability. Fields marked with an * are required.

"*" indicates required fields

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General Information

Business Name*

Federal Employee ID Number*

Mailing Address*

Street Address* Address Line 2 City* State/Prov./Region* ZIP/Postal* Country*

Contact Person*

First Name* Last Name*

Email*

Phone Number*

Fax Number

Web Address

Organization

Individual

Corporation

Partnership

Other

If other, please list.

Annual Revenue*

Date Established*

Current Insurance Program

Prior Insurance*

Yes

Current Insurance Carrier*

Deductible*

How many claims in the last 5 years?*

If there is existing insurance, please attach copies of Declaration Pages from each of your policies. Declarations Pages are the first few pages of the policy that indicate who, where and what is insured, and how much coverage is present.If there is existing insurance, please attach copies of Declaration Pages from each of your policies. Declarations Pages are the first few pages of the policy that indicate who, where and what is insured, and how much coverage is present.

File

Max. file size: 300 MB.

Location Information

Location #1*

Mailing Address

Street Address Address Line 2 City State/Prov./Region ZIP/Postal Country

Year Built*

Square Feet*

Construction*

Frame

Brick

Non-Combustible

Fire Resistive

Do you rent your building?*

If yes, are you required to provide building coverage?

Do you own the building?*

Yes

Building Value*

Sprinklered?*

Alarm System?*

If building is over 30 years old, provides updates for each:

Roof

Heating/Ventilation

Plumbing

Electric

Limits of Insurance

Business Personal Property (BPP limit is the total of all of your furniture, fixtures and inventory – excluding antiques, collections and other Fine Arts):

Number of “Members” (i.e. area businesses) of your Civic Association?*

Fine Art, Antiques, Collections limit

Directors and Officers Liability

Total Assets

Total Payroll

Worker’s Compensation

Total Number of Employees

Full Time*

Part Time*

Estimated Annual Payroll for Employees

Full Time*

Part Time*

Owners/ Officers are included/excluded from workers comp benefits.

Full Time*

Part Time*

Special Events

Total number of attendees and alcohol sales ( Please include brief description):

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