COMMERCIAL SURVEY

COMMERCIAL SURVEY
Do Not Print. Form must be completed online or by calling our toll free number at 1(800) 847-7030 and pressing extension 243 Monday through Friday 8:30am - 4:00pm est.
Last years premium on your policy was based upon certain conditions and/or estimates, and is subject to audit on the anniversary of the policy. Please complete the following questions only for the last policy period. If you need help completing the information, contact your agent. (Please enter a 0 for the questions that do not apply)
Survey Date:	Completed by:
Name on Policy:	Policy #:
Address:	City:
State:	Zip:

During the last policy period, What were your total gross receipts for?
Catering: $
Food Sold: $
Alcohol Sold: $
All other products sold: $
Other Operations Performed: $

During the last policy period:
What was your total payroll? $
How many people do you employ? Full time: Part time:

During the last policy period:
Did you begin any new type of work? Yes No
Did you begin any new type of off premise activity? Yes No
Did you begin any new type of operations? Yes No
Did you open any new location (s)? Yes No If yes, to any of the above questions please explain:

During the last policy period:
Did you hire any contractor/subcontractor? Yes No If yes, describe type of work performed:

Total contract cost: $
Did the contractor provide his/her own general liability & worker's compensation? Yes No
If yes, what is the name of the insurance company?
If work is still in progress, please submit certificates of insurance for general liability and worker's compensation insuring the contactor.

IMPORTANT NOTICE TO POLICYHOLDER "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation." As part of our underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living. A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal, or extension of the insurance to which this application is made. The Applicant, upon written request, will be informed whether or not a consumer report was requested – and if such was requested, informed of the name and address of the consumer reporting agency that furnished the report. The person completing this survey hereby affirms that the statements and representations made herein are true to the best of his/her knowledge.