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Business Insurance Application
Insurance Application
Step
1
of
8
- General Information
12%
General Information
Legal Entity:
*
Select
Individual / Sole Proprietor
Partnership
LLC
Corporation
Non-Profit
Other
Business Entity - Other:
*
Please provide more information
First and Last name:
*
Enter the name of the business owner
DBA:
Doing Business As
Business Name:
*
Contact Phone:
*
Email:
*
We respect your privacy and do not tolerate spam and will never sell, rent, lease or give away your information to a 3rd party. Nor will we send you unsolicited emails.
Enter Email
Confirm Email
Physical Address
Primary business address (physical location, not a P.O. Box)
Address Line 1
*
Address Line 2
City
*
State
*
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
*
Check this box if there is a different mailing address.
Mailing Address
Address Line 1
*
Address Line 2
City
*
State
*
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
*
Business Operations
Provide Description of Business Operations:
*
Describe in detail all the products, services, and/or operations the business provides. Please include business website, if available.
How many years in business under current ownership?
*
How many Owners/Officers?
*
How many years of management experience of owner?
*
How many full time employees?
*
enter 0, if none
Number of part time employees?
*
enter 0, if none
Total Gross Annual Payroll:
*
(Excluding Owners/Officers). Enter 0, if none.
General Liability / Business Owners Insurance Application
Do you currently have General Liability or Business Owners Insurance?
*
Yes
No
Expiration date of the present General Liability or Business Owners insurance policy:
MM slash DD slash YYYY
Select desired effective date:
*
MM slash DD slash YYYY
Annual Gross Sales / Receipts / Commissions:
*
If new business or no prior sales, please enter estimated amount for the next 12 months.
Square Feet of Space Occupied by Applicant:
*
If working from home, enter the sq.f. area at your home office.
Select General Liability insurance limit:
*
General Liability Limit - this is the amount of coverage desired for your products and/or premises. This coverage protects you if someone or something is hurt or damaged by your work or your product or while at your premises.
Select
$300,000 each occurrence / $600,000 aggregate limit
$500,000 / $1,000,000
$1,000,000 / $2,000,000
$2,000,000 / $4,000,000
Other
Other general liability insurance limit:
*
Year building built:
*
Provide information about your physical location
Building Construction Type:
*
Provide information about your physical location
Select
Frame
Joisted Masonry
Non Combustible
Masonry Non-Combustible
Modified Fire Resistive
Fire Resistive
Building Limit:
Building Limit - the expected cost to rebuild the building you own. If the building burned to the ground, what would it cost to rebuild it? The Building Limit also includes any equipment that is permanently attached to the building (air conditioners, etc).
Business Personal Property Limit:
*
The amount of insurance you need to cover all items inside of your building. This should include furniture, fixtures, computers, etc.
Number of stories in the building:
*
Percentage of the building covered by operational sprinklers:
*
enter 0, if none
Select Burglar and/or Fire Alarm type:
Select
None - None
Central/monitored Burglar - Central/monitored Fire
Central/monitored Burglar - Local Fire
Central/monitored Burglar - None
Central/monitored Burglar - Other
Central/monitored Burglar - Smoke
Local Burglar - Central/monitored Fire
Local Burglar - Local Fire
Local Burglar - None
Local Burglar - Other
Local Burglar - Smoke
None - Central/monitored Fire
None - Local Fire
None - Other
None - Smoke
Other - Central/monitored Fire
Other - Local Fire
Other - None
Other - Other
Other - Smoke
Do you have more than 50% interest in any other business?
*
Yes
No
Is the other business listed as a named insured in this application?
*
Yes
No
Have you included the exposures associated with the other business in this application?
*
Yes
No
List the named insured(s) not included in this application:
*
Describe your other ownership interest, including the entities and associated exposures that are not part of this application:
*
Are the named insureds and exposures insured elsewhere?
*
Yes
No
Do any or all the businesses you have more than 50% ownership interest in, work out of the same location?
*
Yes
No
Any General Liability or Property losses in the past 3 years?
*
Yes
No
Prior general liability / business owners insurance losses details:
*
To enter multiple claims click on (+) sign
Date of claim
Claim details
How much was paid
Claim status (open or closed)
Any General Liability insurance coverage in place in the past 3 years?
*
Yes
No
Prior insurance Information:
*
Year
Insurance Carrier
Annual Premium
In the last 3 years, has any insurance company either declined to issue a policy, or cancelled, or failed to renew existing coverage for the business?
*
Yes
No
Reason for Cancellation/Decline:
*
Select
Non-Payment
Losses
Change of Business Operation
Carrier Withdrew
Other
Indicate the frequency of non-payment:
*
Select
Once in the prior year
Once in the past 2 years
Once in the past 3 years
More than once in the past 3 years
Workers Compensation Insurance application
Do you currently have Workers Compensation Insurance?
*
Yes
No
When does your present Workers Compensation insurance policy expire?
MM slash DD slash YYYY
Select desired effective date:
*
MM slash DD slash YYYY
Tax ID # (SSN):
*
This is also known as Federal Employer Identification Number of FEIN
Select Workers Compensation insurance limit:
*
Select
State minimum required
$1,000,000 each accident / $1,000,000 Each Employee / $1,000,000 Policy Limit
$2,000,000 / $2,000,000 / $2,000,000
Do you want to include coverage for the owners / officers?
*
Yes
No
Provide for each company owner / officer:
*
To enter multiple class codes click on (+) sign
Name
Title/Relationship
Ownership %
Duties
Annual Payroll
Include or Exclude?
Employees' Payroll Info
*
To enter multiple class codes click on (+) sign
For example:
Class Code | Duties | Full Time | Part Time | Payroll
8810 Clerical 0 1 $34,000
Class code, if known
Duties
Full Time
Part Time
Annual Payroll
Any losses in the past 4 years?
*
Yes
No
Prior Workers Compensation insurance losses details
*
To enter multiple claims click on (+) sign
Date of claim
Claim details
How much was paid
Claim status (open or closed)
Any Workers Compensation coverage in place in the past 4 years?
*
Yes
No
Prior Insurance Information
*
Year
Insurance Carrier
Annual Premium
In the last 4 years, has any insurance company either declined to issue a policy, or cancelled, or failed to renew existing coverage for the business?
*
Yes
No
Reason for Workers Comp. policy Cancellation/Decline
*
Select
Non-Payment
Losses
Change of Business Operation
Carrier Withdrew
Other
Indicate the frequency of non-payment
*
Select
Once in the prior year
Once in the past 2 years
Once in the past 3 years
More than once in the past 3 years
Enter experience modification (x-mod), if known
Business Auto Insurance Application
Do you currently have Business Auto Insurance?
*
Yes
No
When does your present Business Auto insurance policy expire?
*
MM slash DD slash YYYY
Desired Effective Date
*
MM slash DD slash YYYY
Drivers:
*
Please provide information about each driver you want to be covered by this policy.
To enter multiple drivers click on (+) sign
First Name
Middle Name
Last Name
DOB
DL#
DL State
Marital Status
How many vehicles do you want to add to your policy?
*
Please enter a number from
1
to
100
.
Vehicle 1
Vehicle Details
*
VIN
Year
Make
Model
Vehicle coverage:
*
Liability Only
Full Coverage
Operations Details:
*
Primary Use (personal, business or both)
Current Vehicle Value
Garaging Zip Code
Average daily driving radius
Average jobsites per day
Operations Details:
*
Primary Use (personal, business or both)
Current Vehicle Value
Garaging Zip Code
Average daily driving radius
Average jobsites per day
Comprehensive Deductible
Collision Deductible
Vehicle 2
Vehicle Details:
*
VIN
Year
Make
Model
Vehicle coverage:
*
Liability Only
Full Coverage
Operations Details:
*
Primary vehicle use (business, personal or both)
Current Vehicle Value
Garaging Zip Code
Average daily driving radius
Average jobsites visited per day
Operations Details:
*
Primary vehicle use (business, personal or both)
Current Vehicle Value
Garaging Zip Code
Average daily driving radius
Average jobsites visited per day
Comprehensive Deductible
Collision Deductible
Vehicle 3
Vehicle Details:
*
VIN
Year
Make
Model
Vehicle coverage:
*
Liability Only
Full Coverage
Operations Details:
*
Primary Use (personal, business or both)
Current Vehicle Value
Garaging Zip Code
Average daily driving radius
Average jobsites per day
Operations Details:
*
Primary Use (personal, business or both)
Current Vehicle Value
Garaging Zip Code
Average daily driving radius
Average jobsites per day
Comprehensive Deductible
Collision Deductible
Vehicle 4
Vehicle Details:
*
VIN
Year
Make
Model
Vehicle coverage:
*
Liability Only
Full Coverage
Operations Details:
*
Primary Use (personal, business or both)
Current Vehicle Value
Garaging Zip Code
Average daily driving radius
Average jobsites per day
Operations Details:
*
Primary Use (personal, business or both)
Current Vehicle Value
Garaging Zip Code
Average daily driving radius
Average jobsites per day
Comprehensive Deductible
Collision Deductible
Vehicle 5
Vehicle Details:
*
VIN
Year
Make
Model
Vehicle coverage:
*
Liability Only
Full Coverage
Operations Details:
*
Primary Use (personal, business or both)
Current Vehicle Value
Garaging Zip Code
Average daily driving radius
Average jobsites per day
Operations Details:
*
Primary Use (personal, business or both)
Current Vehicle Value
Garaging Zip Code
Average daily driving radius
Average jobsites per day
Comprehensive Deductible
Collision Deductible
Vehicle 6
Vehicle Details:
*
VIN
Year
Make
Model
Vehicle coverage:
*
Liability Only
Full Coverage
Operations Details:
*
Primary Use (personal, business or both)
Current Vehicle Value
Garaging Zip Code
Average daily driving radius
Average jobsites per day
Operations Details:
*
Primary Use (personal, business or both)
Current Vehicle Value
Garaging Zip Code
Average daily driving radius
Average jobsites per day
Comprehensive Deductible
Collision Deductible
Coverage Options
in thousands of dollars, i.e. 50/100 = $50,000 / $100,000
Bodily Injury Split Limit / Combined Single Limit:
*
Select
No Coverage
15/30 split limit
25/50 split limit
50/100 split limit
100/300 split limit
250/500 split limit
100 CSL
300 CSL
500 CSL
750 CSL
1000 CSL
Uninsured/Underinsured Bodily Injury:
*
Select
No Coverage
15/30
25/50
30/60
50/100
100/100
100/300
250/500
300/300
500/500
750/750
1000/1000
Property Damage:
*
Select
No Coverage
10
15
25
50
100
Property Damage:
Included in Combined Single Limit
Medical Payments:
*
Select
No Coverage
1
2
5
10
Uninsured Motorist Property Damage:
*
Select
No Coverage
3.5
Hired / Non-Owned Auto:
Include Hired Auto
Include Non-Owned Auto
Umbrella Detail
Umbrella Limit
*
Please select
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
$7,000,000
$8,000,000
$9,000,000
$10,000,000