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Select Line of Business Insurance
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Select one or several lines of business insurance. Multi-line discounts are available for 2 or more lines of business insurance placed with one carrier.

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- General Liability
- Business Owners: Liability and Property
- Professional Liability / E&O
- Workers Compensation
- Commercial Auto
- Umbrella
- Directors & Officers (D&O)

General Information
Legal Entity:*
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
Primary Business Address*
(provide your physical location; P.O. Box not allowed)

Street Address Address Line 2 City State ZIP Code
Mailing Address*
Same as previous

Street Address Address Line 2 City State ZIP Code
Referral Code
If you were referred to us please provide the referral 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.
Other general liability insurance limit:*
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.
Year building built:*
Year Roofing was last updated:*
Year Plumbing was last updated:*
Year Heating/HVAC was last updated:*
Year Electrical was last updated:*
Building Construction Type:*
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:
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 the insured has more than 50% ownership interest in work out of the same location?*
- Yes
- No
Any losses in the past 3 years?
- Yes
- No

Prior general liability / business owners insurance losses details

Date of Claim	Claim Details	How much was paid	Claim Status	Actions

There are no Claims.

Any coverage in place in the past 3 years?
- Yes
- No
Prior Insurance Information
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:*
Indicate the frequency of non-payment:*

Workers Compensation Insurance application
If Workers Comp. coverage is not needed, please navigate back to the Select Line of Business Insurance screen by clicking the "Previous" button several times, and deselect the Workers Compensation checkbox.
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):*
Select Workers Compensation insurance limit:*
Do you want to include coverage for the owners / officers?*
- Yes
- No

Owner/Officer Info

Owner/Officer/Executive Full Name	Position with the company	Percentage owned	Workers Comp. Coverage selection	Actions

There are no Owners/Officers.

Employee 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 Comp. Losses

Date of Claim	Claim Details	How much was paid	Claim Status	Actions

There are no Claims.

Any Workers Compensation coverage in place in the past 4 years?
- Yes
- No
Prior Workers Compensation Insurance Information
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*
Indicate the frequency of non-payment*
Enter experience modification (x-mod), if known

Business Auto Insurance Application
If Business Auto coverage is not needed, please navigate back to the Select Line of Business Insurance screen by clicking the "Previous" button several times, and deselect the Business Auto checkbox.
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

Vehicle Info

VIN	Year	Make	Model	Vehicle Use	Annual Mileage	Date Purchased	Current Odometer Reading	Ownership Status	Garaged at Different Address	Address	Medical Payments	Full coverage or liability only?	Uninsured Motorist Property Damage	Comprehensive Deductible	Collision Deductible	Glass Deductible	Limited Waiver of Collision Deductible	Roadside Assistance	Rental Reimbursement	Actions

There are no Autos.

Driver Info

Name	Date of Birth	Gender	Marital Status	License Number	License State	U.S. Date Licensed	Actions

There are no Drivers.

Coverage Options
in thousands of dollars, i.e. 50/100 = $50,000 / $100,000
Bodily Injury Split Limit / Combined Single Limit:*
Uninsured/Underinsured Bodily Injury:*
Property Damage:*
Property Damage:
Hired / Non-Owned Auto:
- Include Hired Auto
- Include Non-Owned Auto

Umbrella Detail
If Umbrella coverage is not needed, please navigate back to the Select Line of Business Insurance screen by clicking the "Previous" button several times, and deselect the Umbrella checkbox.
Umbrella Limit*

NOTICE TO APPLICANT – PLEASE READ CAREFULLY
FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED, AS AUTHORIZED AGENT FOR ALL PERSONS AND ENTITIES PROPOSED FOR THIS INSURANCE, DECLARES THAT TO THE BEST OF HIS/HER/THEIR KNOWLEDGE THE STATEMENTS HEREIN ARE TRUE AND COMPLETE.
THE INSURER IS AUTHORIZED TO MAKE ANY INQUIRY IN CONNECTION WITH THIS APPLICATION.
SIGNING THIS APPLICATION DOES NOT BIND THE INSURER TO ISSUE, OR THE APPLICANT TO PURCHASE, ANY INSURANCE POLICY.
THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE INSURER.
THE INSURER WILL HAVE RELIED UPON THE STATEMENTS MADE IN THIS APPLICATION AND ATTACHMENTS IN ISSUING THIS COVERAGE PART.
IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE EFFECTIVE DATE OF THE COVERAGE PART, THE APPLICANT MUST NOTIFY THE INSURER, WHO MAY MODIFY OR WITHDRAW THE QUOTATION.

FRAUD STATEMENT
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
FRAUD STATEMENT TO ALABAMA APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
FRAUD STATEMENT TO ARKANSAS APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
FRAUD STATEMENT TO COLORADO APPLICANTS
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
FRAUD STATEMENT TO DISTRICT OF COLUMBIA APPLICANTS WARNING:
It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
FRAUD STATEMENT TO FLORIDA APPLICANTS
Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
FRAUD STATEMENT TO KENTUCKY APPLICANTS
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.
FRAUD STATEMENT TO LOUISIANA APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
FRAUD STATEMENT TO MAINE APPLICANTS
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.
FRAUD STATEMENT TO MARYLAND APPLICANTS
Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
FRAUD STATEMENT TO NEW JERSEY APPLICANTS
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
FRAUD STATEMENT TO NEW MEXICO APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
FRAUD STATEMENT TO NEW YORK APPLICANTS
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.
FRAUD STATEMENT TO OHIO APPLICANTS
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
FRAUD STATEMENT TO OKLAHOMA APPLICANTS WARNING:
Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
FRAUD STATEMENT TO OREGON APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents materially false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
FRAUD STATEMENT TO PENNSYLVANIA APPLICANTS
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 subjects such person to criminal and civil penalties.
FRAUD STATEMENT TO RHODE ISLAND APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance, including failing to disclose whether the applicant or applicants have been convicted of any degree of the crime of arson, is guilty of a crime and may be subject to fines and confinement in prison.
FRAUD STATEMENT TO TENNESSEE APPLICANTS
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
FRAUD STATEMENT TO VERMONT APPLICANTS
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 may be a crime and subjects such person to criminal and civil penalties.
FRAUD STATEMENT TO VIRGINIA APPLICANTS
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
FRAUD STATEMENT TO WASHINGTON APPLICANTS
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
FRAUD STATEMENT TO WEST VIRGINIA APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
I agree
Signature:*

Get a Quote Now

Step 1 of 9 - Line of Business

Select Line of Business Insurance

General Information

Business Operations

General Liability / Business Owners Insurance Application

Prior Insurance Information

Workers Compensation Insurance application

Prior Workers Compensation Insurance Information

Business Auto Insurance Application

Coverage Options

Umbrella Detail

Directors & Officers

Employment Practices(EPL)

Class code, if known	Duties	Full Time	Part Time	Annual Payroll