Express Business Insurance Questionnaire

This form is not an application for insurance. Once this form is completed and sent to us, you will be contacted by a member of our licensed, friendly, professional sales staff to discuss your specific insurance questions and needs. No coverage will be assumed bound or covered until written confirmation is received from Hartland Insurance Group.

Business Name

Business Entity

Business Email

Business Address

City/State

Postal Code

Phone Number

Description of business operations:

Annual Gross Sales

Number of Employees

Years in Business

Has there been any losses or claims in the last three years?
YesNo

Has any insurance policy been cancelled or non-renewed in the last three years?
YesNo

If yes, please explain

Building Construction Type

When was the building built?

What is the building square footage

What year was the following updated:

Roof	Heating & Cooling	Electrical	Plumbing
Year Updated:	Year Updated:	Year Updated:	Year Updated:

Please describe any additional buildings on the property:

Please describe the building security systems :

What is the value of all building contents:

Please describe any specialized tools or equipment:

Please give annual payroll per job description:

Job Description	Annual Payroll
1	1
2	2
3	3
4	4
5	5

Business Auto Information

Please list all that apply:

Year	Make	Model	VIN #
Vehicle 1	Vehicle 1	Vehicle 1	Vehicle 1
Vehicle 2	Vehicle 2	Vehicle 2	Vehicle 2
Vehicle 3	Vehicle 3	Vehicle 3	Vehicle 3
Vehicle 4	Vehicle 4	Vehicle 4	Vehicle 4
Vehicle 5	Vehicle 5	Vehicle 5	Vehicle 5

Please list all that apply:

Vehicle #	Liability	Comp	Collision
Vehicle 1	Vehicle 1	Vehicle 1	Vehicle 1
Vehicle 2	Vehicle 2	Vehicle 2	Vehicle 2
Vehicle 3	Vehicle 3	Vehicle 3	Vehicle 3
Vehicle 4	Vehicle 4	Vehicle 4	Vehicle 4
Vehicle 5	Vehicle 5	Vehicle 5	Vehicle 5

Comprehensive Deductible

Collision Deductible

Please list all that apply:

First Name	Last Name	Date of Birth	Driver's License #
Driver 1	Driver 1	Driver 1	Driver 1
Driver 2	Driver 2	Driver 2	Driver 2
Driver 3	Driver 3	Driver 3	Driver 3
Driver 4	Driver 4	Driver 4	Driver 4
Driver 5	Driver 5	Driver 5	Driver 5

Please check which coverage to quote:

PropertyLiabilityBusiness AutoWorkers CompUmbrellaOther

Upload current policy declarations pages here:

By submitting your information, you agree to the following terms:

Insurance Coverage cannot be bound or changed via submission of this online form/application, e-mail, voice mail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent and or your insurance company.

Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. A proposal is not an insurance policy. Please refer to the actual policy for coverage limits, definitions and coverage exclusions.