Gas Station Insurance Questionnaire

Section 1: General Business Information

Business Name:

First Name:

Last Name:

Phone *

Email *

Tax ID:

Gas Station Address(es):

Mailing Address (if different):

Is This Location Part of a Franchise? (Y/N) If Yes, Franchise Name::

Year Business Started at This Location:

Section 2: Property Details

Year the Building Was Built:

What is the Building Made Of? (e.g., brick, concrete, steel):

Roof Type and Year Last Replaced:

Number of Stories:

Total Size of the Building (Square Feet):

Renovations (if any): Electrical, Plumbing, Roof:

Section 3: Gas Station-Specific Details

Number of Fuel Pumps:

Type of Fuel Sold (e.g., gasoline, diesel, propane, EV charging stations):

Are There Underground Storage Tanks? (Y/N):

If Yes - Tank Capacity, Year Installed, Last Inspection Date:

Are There Any Additional Services Offered? (Check all that apply):

Section 4: Safety and Security Details

Fire Protection Systems:

Fire Extinguishers (Y/N):

Sprinklers (Y/N):

Fire Alarms (Y/N):

Security Systems:

Security Cameras (Y/N):

Alarm System (Y/N):

On-Site Security Guard (Y/N):

Distance to Nearest Fire Hydrant:

Distance to Nearest Fire Station:

Section 5: Business Operations

Annual Revenue:

Number of Employees:

Hours of Operation:

Estimated Daily Customer Traffic:

Do You Sell Alcohol? (Y/N):

If Yes, Do You Have an Alcohol License? (Y/N):

Do You Sell Tobacco Products? (Y/N):

Section 6: Current Insurance and Loss History

Do You Have Current Insurance? (Y/N):

Provider Name:

Policy Expiration Date:

Current Coverage Limits (if known):

Have You Had Any Claims in the Past 3–5 Years? (Y/N):

If Yes, Provide Details:

Type of Claim:

Amount Paid:

Steps Taken to Prevent Future Issues:

Section 7: Additional Coverage-Specific Details

Workers’ Compensation

Job Descriptions for Employees:

Annual Payroll:

Workplace Safety Measures (e.g., training, PPE):

Commercial Auto

Number of Business Vehicles:

Type of Vehicles (e.g., trucks, delivery vans):

What Are the Vehicles Used For?:

Driver Information (e.g., licenses, driving records):

Cyber Protection

Do You Store Customer Payment Information? (Y/N):

What Type of Point-of-Sale (POS) System Do You Use?:

Do You Have Security for Your Systems (e.g., antivirus, encryption)?:

Have You Had Any Cybersecurity Breaches? (Y/N):

Umbrella/Excess Coverage

What Is Your Current Coverage Limit for General Liability?:

Do You Want Additional Coverage Above Your Existing Limits? (Y/N):

Section 8: Additional Notes

Please provide any additional details about your business that may be relevant:

Upload your Loss Runs for last 3-5 years:

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