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Commerical Insurance Discovery Form

"*" indicates required fields

Step 1 of 9

11%

General Business Information

Business Legal Name*

This is how the name will ready on the policy contract so very important that this be accurate and correct.

DBA (if applicable)

Owner's Name*

First Last

Owner's DOB*

MM slash DD slash YYYY

Is the owner the same as the contact person for this submission?*

Yes

Contact person's info*

Name:

Relation to business:

Best contact phone number*

Best Email*

Organization Type*

Number of Owners*

Tax ID Number

Required for Work Comp quote requests; do not enter SSN.

Business Website Address (if available)

If no dedicated URL, please enter any social media URLs for your business, as underwriting will search for business online.

Year Business Started*

Please enter a number from 1955 to 2025.

Years of Industry Experience*

Mailing Address*

Street Address City State ZIP Code

Physical Address*

Same

Different

Business Physical Address*

Street Address City State ZIP Code

Type of Business*

Description of your business*

Please provide a brief description of your business operation to help us understand all of your operations.

Insurance Experience

Have you ever worked with a insurance broker before?*

Yes

Do you have any contract requirements that need to be met with these policies (ie specific coverage, limits of liability or special wording)?*

If yes, you will be given the opportunity to upload a copy of the contract requirements later in the application process.

Yes

Why are you shopping for insurance?*

Please check all that apply

New Venture - never have had insurance coverage

Existing business with NO current coverage

Price

Bad Claims Experience

Poor Customer Services Experience

No local representation

Other

How did you first hear about Leal Insurance Services?*

I am a current personal lines (ie Home, Auto, etc) customer of LIS

Family/Friend Referral

Channel Partner Referral (Mortgage Broker, Realtor, Other Insurance agent)

Google Search

Social Media Post (Facebook, Instagram, Twitter, TikTok)

Local Event

Email Marketing Campaign

Other

What is your target price for the policies you are interested in quoting?*

Please provide a realistic expectation of pricing for the requested quotes so we know what target to shoot for.

Who referred you so we can send them a thank you:*

Have you or your business had any claims or judgements filed against you in the 5 years?*

Yes

Will we be replacing existing coverage for your business that is currently in place?*

Yes

Claims Experience

Prior Insurance Information

Prior policy information*

Please enter the information for each policy you are looking to replace. Use the "+" sign to add another line. Okay to enter JUST the name of the current insurance company and leave the rest blank if unknown.

Name of current insurance co (NOT agency)

Current policy expiration date

Current premium

Do you agree to help us obtain copies of your loss run report (ie claims history) showing any losses/claims for the last 5 years on all requested coverages?*

Yes

General Liability Coverage Selection Rejection

Check this box if you wish to DECLINE General Liability coverage for your business.

What is the reason(s) you're declining coverage?*

Not looking to replace the current coverage you have in force.

I don't think I need this coverage.

Other

Other reason you're not interested in this coverage:*

General Liability Questions

Contractor Type*

Please select the contractor type that best fits your business. On the next page, you can describe in more detail.

Occupied Sq Ft*

This is the occupied square footage for your business. If you have an office in your home, please list the size of the space for your home office.

Number of Employees*

Please indicate the number of W2 and uninsured independent contractors your business has. DO NOT include owners in this number.

Estimated Annual Gross Sales/Revenue*

PLEASE NOTE: This should be the total estimated gross sales or revenue for the upcoming 12 month period BEFORE any anticipated expenses, including, but not limited to: payroll, subcontract cost, materials, labor, taxes, etc.

Please enter a number greater than or equal to 10000.

Estimated Annual Payroll*

PLEASE NOTE: This should be the estimated payroll amount for W2 employees & 1099 independent contractors that you do not require to have their own insurance policy or have a subcontractor agreement with. DO NOT INCLUDE owners' payroll in this number.

Please enter a number greater than or equal to 0.

Are you interested in Professional Liability coverage for your business?*

Most General Liability policies will EXCLUDE coverage for any advice, consultation, or design work offered by your business. You can find that coverage for your business in a professional liability policy.

I would like a quote for this coverage.

I understand that coverage for any design, advice, or consultation work may not be available on my General Liability Policy and choose to DECLINE this coverage for my business at this time.

I have this coverage elsewhere and am not interested in a quote at this time.

I'm not sure if I need this coverage.

Are you interested in Excess Liability / Umbrella coverage?*

I would like a quote for this coverage.

I'm not sure if I need this coverage.

I wish to DECLINE this coverage at this time.

What limit of excess liability or umbrella coverage is being requested/required?*

Do you have an active contractor's license?*

Yes

Type of license:*

License Number:*

Commercial Work %*

Please enter a number from 0 to 100.

Residential Work %*

Please enter a number from 0 to 100.

Total (should equal 100%):*

New Construction %*

Please enter a number from 0 to 100.

Remodel %*

Please enter a number from 0 to 100.

Total (should equal 100%)*

How often do you use a written contract with your customers?*

Always

Sometimes

Never

Do you subcontract ANY work?*

Yes

What is the average cost of a project?*

PLEASE NOTE: We are looking for the average total cost you charge a customer for a project you are working on.

How many projects do you expect to complete in the next 12 months?*

In the last 5 years have you worked on or plan on working on any of the following:*

Check all that apply

Any condo, townhomes or tract home projects (work in any subdivision for a home builder with more than 20 homes)

Stand alone roofing jobs

Any work outside of Texas

Public work (i.e. street work, hospital, schools, prisons, public utilities, airports, etc)

Water or fire restoration (i.e. asbestos removal, mold remediation, radon mitigation, etc)

Fireproofing, Sprinkler/Fire Prevention or fire suppression work?

Any foundation repair for existing structures

Any work on pools

Exterior work above 2 stories or below surface

None of the above

Do you offer any of the following services:*

Check all that apply

Outside surfacing cleaning (building siding, roofs, windows, etc)

Cleaning or washing of aircraft or ship hulls

Clean the interior of tanks

Exterior work above 2 stories

Cleaning solutions that are non-toxic and non-caustic

Parking lots, driveways, sidewalks

Maximum PSI of the pressure apparatus used?*

Do you perform ANY work in and/or around the oil and gas industry?*

This could be any of the following, but not limited to: any work on new or existing live natural gas lines, drilling derricks, operating crude or paraffin oil lines, within refineries, any over-the-hole, off-shore welding work?

Yes

Do you perform any auto or truck work, or work on any heavy machinary*

This could be any of the following, but not limited to: auto or truck customization or repairs, trailer hitches, cranes, conveyors, hydraulics, etc

Yes

Do you do any structural welding work?*

This could be any of the following, but not limited to: bridge construction, high rise buildings, metal buildings, stairs, catwalks, railings, etc.

Yes

Do you offer any of the following services:*

Check all that apply

Hot Tar Application

Torch Down

Asphalt Shingle Installation

Metal roofing

Polyurethane foam

None of the above

What precautions are taken to protect the public from potential injury on jobsite and the surrounding property from potential damage?*

Does Applicant have a current and active liquor permit or license, as required by local and/or state laws, to serve and sell alcoholic beverages at its restaurant, bar, or tavern*

Yes

Estimated Annual Alcohol Gross Sales over the next 12 months:*

Estimated Annual Gross Sales for merch, nonfood items, etc (DO NOT include Alcohol sales in this estimate):*

Describe Other Sales:*

Describe Applicant’s prior restaurant / bar ownership or management experience, including length of time:*

What is the latest your business closes?*

Any of the follow apply to your business*

Wood burning stoves or fireplaces on the premises

Open fire grilling

Deep fat frying

Open Broiling

Solid Fuel Cooking

Roasting

Table side cooking

Barbecue/smokehouse

None of the above

Are any of those cooking apparatuses on premises?*

Yes

Where are they located?*

Inside a building

Beside a building

Feet from the building*

Please check all that apply to your business*

Has a current and active permit or license, as required under local and/or state laws, to provide food service at its restaurant, bar, or tavern

Your license has never been suspended or revoked

Have never been fined or cited for a critical or severe violation of your license or the local/state health code

Is currently compliant with local and state laws and regulations governing food establishments

Keep records on stock rotation and cooler temperatures

Have warning posted on the premises or on menus alerting customers to the hazards associated with consuming raw or undercooked foods

Have written policies and procedures for the proper handling, preparation and service of raw seafood and meat

Please check all the apply*

Your liquor permit/license has never been suspended / revoked

You've never been fined or cited for violating your license

None of your employees have ever been cited or fined for being in violation of any liquor law, alcoholic beverage control law, or similar law

All individuals who serve alcohol required to have active certification through TIPS or another certified program, prior to serving customers alcohol

You have written guidelines and procedures in place for verifying the age of patrons, to prevent the sale of alcohol to minors

You have written guidelines and procedures in place for cutting off patrons, and not over-serving patrons, that are visibly intoxicated and staffed are all trained

Does your business provide or allow any of the following:*

Athletic facilities, sports courts, or playgrounds on the premises

Table Service

Off-site catering

Dance Floor

Food/alcohol delivery

Live Entertainment (ie Musical acts, DJ, Karaoke, Comedy shows, etc)

BYOB

Hookah

Drinks specials that extend past 9:00 pm

Bottle Service

Alcohol sales to customers for off-premises consumption

Serve single drinks larger than 24 ounces

Drinking games (ie Beer Pong, Shot Games, etc)

Amusement Games (ie Pool tables, dart board, shuffle board, corn hole, juke box, gambling or arcade gamesetc)

Mechanical bulls, nude or topless dancing, or pyrotechnics

Special events that allow for increased capacity or private events

Table side cooking (ie cold / hot cooking, open cooking, hibachi, etc)

Valet Parking

None of the above

Please check all that apply

Sq ft of the dance floor:*

What percentage of your estimated annual gross revenue comes from off-site catering?*

Please enter a number less than or equal to 100.

Valet parking operations

With regards to the valet parking operations you confirm the following:

- Prior to hire, the public driving record of all employed valet parking attendants are reviewed, to confirm that they have no DUI / DWI violations, criminal or civil traffic violations, citations or other offense on their driving record

- All employed parking attendants have a current and valid driver's license

- If valet parking is contracted to a third-party that you require evidence of third party's garage-keeper liability insurance, at least annually

Food delivery is offered via the following services:

Please check all that apply

Employed delivery service

Contract or partner with a third-party delivery service like Uber Eats, DoorDash, Grubhub, etc

Does your business have any bouncers or security staff?*

Yes

Please check all that apply regarding your security:*

Armed Guards or off-duty police officer

Unarmed doormen/bouncers

Bag checks, pat downs or frisking at the door

Metal detector at the entrance to the premises

Video surveillance through out the premises

Responsible for ID checks

Maintain Incident logs documenting when persons are refused service or other alcohol related events

None of the above

Is your security personnel employed or contracted*

Employees

Contracted

How many days do you keep the video tapes?*

Confirm the following:

All employed security staff are required to sign waivers; have confirmed - prior to hiring - that you have reviewed the public record of all employed security, to confirm that they have no criminal or civil violations, citations or other offenses on their record;.

Confirm the following:*

Obtain proof of third-party security company's general liability insurance via Certificate of Insurance at least annually; require limits of liability equally your own; require written agreement with independent security contractor indemnifying insured.

Please check all the services below that you provide:*

Arborist

Artificial turf install

Holiday lighting install

Tree Trimming

Landscaping

Lawn care/maintenance

Stump grinding

None of the above

Please check all that apply regarding the services your provide:*

Do any work around power lines for utility companies or governmental entities

Any work for railroad companies

Do you use any pesticides or herbicides

Use cranes in your operations

None of the above

Please provide additional details*

Please provide as much detail as possible about heights climbed, cherrypicker/man-buckets used, safety devises used, ladders used, how far down below ground level dug, etc

Describe what type and how often of pesticides or herbicides:*

If using cranes, are you leasing or renting from others or using owned cranes?*

If leasing/renting, please describe if you are leasing/renting with operators and operations and frequency for use of cranes

Type of retail:*

Subcontractor Questions

Do you generally use the same subcontractors?*

Yes

Requirements for your subcontractors included in your subcontractor agreement:*

Check all that apply

Additional Insured status in favor of applicant

Waiver of Subrogation in favor of applicant

Primary & Noncontributory Wording in favor of applicant

Matching limits of liability limits

COI kept on file for a minimum of 3 years

None of the above

Estimated annual cost of INSURED subcontractors (incl. materials and labor):*

Estimated annual cost of UNINSURED subcontractors (incl. materials and labor):*

Give a brief description of the work typically subbed out:*

Garage Liability & Garage keepers Coverage

Which one of the options below best describes your business:*

Do you perform any work on vehicle frames?*

This could be repairing or welding of vehicle frames or wheels.

Yes

Type of security that surrounds the property:*

Check all that apply.

Fully fenced-in lot

Partially fenced-in lot

Fully enclosed building

No vehicles kept overnight ever

Other

# of vehicles kept on your lot overnight:*

Average VALUE of the vehicles your business works on:*

# of vehicles your business SELL on a monthly basis:*

Does your business offer any of the following services:*

Check all that apply.

For-hire Towing (no repo)

Forced repo towing

Loaner/rental car arrangements

Raodside service

Mobile service (i.e. vehicle repairs or detailing on a customer's premises)

Used tire sales/retreading

Other

None

What type of vehicles does your business perform work on or offer any of the following for sale?*

Check all that apply.

Private passenger / Light duty trucks

Cargo vans / Medium sized trucks

Heavy duty / oversized trucks

Heavy machines and equipment

Other

What percentage of your overall sales is for used tires or retreading?*

Please provide additional details for your "Other" answers above:*

Workers Comp Coverage Selection Rejection

Check this box if you wish to DECLINE Workers Compensation coverage for your business.

What is the reason you're declining this coverage?*

I don't have any W2 employees or 1099 independent contractors

I don't think I need this coverage.

Other

Other reason you're declining this coverage:*

Workers Comp Questions

Owner Partner Coverage Selection of Rejection*

INCLUDE Owner(s) / Partner(s) in WC coverage

EXCLUDE Owner(s) / Partner(s) in WC coverage

List all NAICS/SIC codes for any type of work your employees do for you*

If you don't know the NAICS/SIC codes, please describe as best you can the type of work your employees do you. Please also breakdown the percentage of your payroll for each class/code.

Class Code (or Type of Work)

Percentage of Payroll

Property Coverage Selection Rejection*

Please select all that apply

Building Coverage

Business Personal Property Coverage

Check this box if you wish to DECLINE all property coverage for your business.

Building Property Questions

Is this for a purchase?*

Yes

Estimated Closing Date:*

MM slash DD slash YYYY

Purchase Price:

% of building that is VACANT:*

% of building occupied by you (owner):*

Year the building was built:*

Please enter a number less than or equal to 2025.

Total Building Sq Ft:*

Is there a sign on premise not attached to the building:*

Yes

Estimated cost to replace the sign:*

Type of property*

# of stories*

Type of Alarm*

None

Local Monitored / Video Surveillance

Central Monitored (Paid service like: ADT, Vivant, SimplySafe, etc)

% of building sprinklered:*

Mechanical Updates Affirmation*

I confirm that the property we are looking to insure does not contain any undesirable electrical elements (including but not limited to Federal Pacific (FPE) Stab-lock panel which has been found to be a fire hazard, fuse, knob and tube or aluminum wiring), and that plumbing and electrical elements are up to building code. I understand that a physical property inspection will be completed. If any undesirable elements are found to be present on the property, it will require remediation or coverage for the property may be set up to cancel.

Older Building Questionnaire

Year of last major ELECTRICAL update to the building*

Type of ELECTRICAL*

Year of last major PLUMBING update to the building*

Type of PLUMBING*

Year of last major HVAC update to the building*

Type of HVAC*

Year of last major ROOFING update to the building*

Type of ROOFING*

Business Personal Property Questions

Had the building been updated in the last 20 years?*

We're looking for updates to the following systems: HVAC, Plumbing, Electrical, Roof.

Yes

Amount of Business Personal Property Coverage*

Please entered the desired coverage limit of business personal property. This is everything inside the space you are occupying, including but not limited to: furniture, decor, electronics, equipment, etc.

Please enter a number greater than or equal to 0.

Please provide a brief description of the updates to the building and when they occurred:*

Tenant Information

Would you like to upload a copy of your rent rolls or manually enter the information on this application for each tenant?*

Upload rent rolls

Manually enter tenant information

Rent Roll

Commercial Auto Coverage Selection Rejection

Check this box if you wish to DECLINE Commercial Auto coverage for your business.

What is the reason you're declining this coverage?*

I do not use a vehicle in the course of my business to transport goods, materials or people.

I don't have any branding logos, magnets, wraps or call-to-actions that brings attention to my business on any vehicles

My Business is not a titled owner of any vehicle.

I don't have any contract requirements that requires this coverage.

I don't think I need this coverage

Other

Other reason you're declining this coverage:*

Commercial Auto Questions

Do you have a DOT# / MC# or plan to get one in the next 6 months?*

Yes

DOT #*

If unavailable or not applicable, enter: "N/A"

MC #*

If unavailable or not applicable, enter: "N/A"

What is the average drivings radius for your business*

Please enter the average driving distance from your garaging address for the owned vehicles.

Average number of jobsites visited daily:*

Please enter the average number of jobsites visited by your covered vehicles on a daily basis.

Auto Liability Limit Requested:*

CSL = Combined Single Limit

Would you like to include any of the following coverages on your quote?*

Hired Auto Coverage

Non-owned Auto

Uninsured/Under-insured

Personal Injury Protection

Roadside Assistance

Cargo Coverage

Trailer Interchange

None of the above

Check all the coverage your are interested in:

Are any vehicles used in the business leased or rented on a long-terms basis?*

Yes

Does the business have a GL/BOP policy in force?*

Yes

Interested in Telematics Discount?*

Yes

# of trailers to be included in Trailer Interchange coverage*

Please list the type(s) of cargo being carried and percentage:*

Example: "Raw Construction Materials - 30%" Use the "+" to add more lines as needed.

Cargo coverage limit requested:*

Any additional coverage notes, requests, requirements:

How would you like to provide the driver list?*

Manually Enter all drivers now

Email a list of drivers to My Insurance Group

How would you like to provide the vehicle list?*

Manually enter all vehicles now

Email a list of vehicles to My Insurance Group

Drivers Information

You can add multiple drivers by clicking on "Add Entry"

Vehicle Information

You can add multiple vehicles by clicking on "Add Entry"

Any other coverages you would like a quote for?

Directors & Officers (D&O)

Cyber Liability

Other

Please describe the additional coverage you would like a quote for:*

File upload

Please use this opportunity to upload any contract requirements that you need met with these policies, loss runs (claims experience), current policy information, rent rolls, or current policy copies so that we are quoting appropriately.

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB.

Affirm & Consent*

I consent & affirm the following is true and correct:

The application information is true and correct to the best of my knowledge.

By submitting this request you are authorizing Leal Insurance Services, its affiliates and carrier partners the access to pull the necessary reports (i.e. claims, credit, and loss history) to confirm the data submitted.

Submitting your quote request does not constitute a binding confirmation of a new or revised insurance coverage.

Leal Insurance Services is committed to respecting your privacy and communication preferences. So that we may remain compliant with state and federal regulations, we need your expressed permission to communicate with you through phone, text and email as needed.

You may opt-out of all future communication at any time by making your preferences known to us.

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