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SAM Insurance Full Term Insurance Quote Application
Step
1
of
4
25%
SAM Insurance Limits
What SAM coverage limits do you need?
(Required)
Any limit (not specified, just need it to be included)
$50,000
$100,000
$500,000
$1M Each occ / $1M Aggregate
$1M Each occ / $2M Aggregate
$1M Each occ / $3M Aggregate
Other Limit
Enter the SAM limits you are required to have for your special event?
(Required)
Do you have a copy of the insurance requirements or contract that ask you to carry the SAM limits you requested above?
(Required)
A copy of the insurance requirements or contract requesting SAM limits of $1M/$2M or higher will be required by the carrier to approve these limits. Without those requirements, a SAM quote may not be provided. If you don’t have the requirements now, you can still proceed with the application, but before a quote is released, you will need to provide a copy of the contract or SAM insurance requirements.
Yes
No
Upload your insurance requirements here:
(Required)
Drop files here or
Select files
Max. file size: 512 MB.
Customer Details
Named Insured
(Required)
This is the name that will be listed on your insurance policy and certificate of insurance. If you have a DBA, state it as follows: for example, ABC Inc DBA XYZ Services.
Business Entity Type
(Required)
Individual
Partnership
LLC
Corporation
Non-Profit
Other
Entity Type – OTHER – please provide details:
(Required)
Tax Exempt Status
(Required)
Yes
No
Customer Contact
Primary Contact or C/O
(Required)
First
Last
Email Address
(Required)
Phone
(Required)
Website
Physical Address (No PO Box):
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Is your mailing address same as physical?
(Required)
Yes
No
Mailing Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
What is the square footage occupied at your physical address?
(Required)
What is your annual gross payroll for owners, W-2 employees, and 1099 subcontractors?
(Required)
What is your annual gross revenue?
(Required)
Underwriting
Select Your Business Category:
(Required)
You can start typing to find your category. If you can’t find it, select “ALL OTHER PROFESSIONAL SERVICES AND PROFESSIONS”.
Academic Testing Services
Accident Reconstruction
Administrative/Office Support Services
Adult Education
Advertising Agency
Aerobics Studios (Including Barre)
Alarm Design Services
Alcohol and Drug Rehab
Alumni Associations
Animal Grooming
Answering Service Appraiser
Aquariums
Arbitrator
Arboretums
Arboretums Associations (non-trade)
Arborist
Archaeological/Historical Consultant
Archiving/Document Management
Art/Gem/Jewelry Appraisal & Consulting
Association Management
Associations (non-trade)
Auctioneer
Audio/Visual Consultant
Background Check/Screening Services
Bankruptcy Counseling Service
Bar Association
Before & After School Educational Programs
Big Brother/Big Sister
Billing Services
Bookkeepers/Tax Preparers
Boys & Girl Clubs
Business Associations
Call Centers
Camps (non-sports)
Caterer
Chamber of Commerce
Churches
Claims Adjuster
Claims Administration
Cleaning Services
Coaches/Instructors
Coding Services/Electronic Data Processing
Community Action Program
Community Center
Community Outreach Services
Compliance Consultant
Computer Forensics Investigator
Computer Lessons
Concierge Services
Condominium Associations (GL Only)
Conservation Groups
Cooperatives
Copy Services
Cost Containment Services
Counseling Offices
County Clerks/Recorders
Courier/Messenger Service
Court Reporter
Credit Counseling
Crisis Center
Dance Instructions
Dance Instructor
Data Collection Services
Daycare Center
Document Destruction/Management
Economic/Demographic Consultant
Educational Consultant
Employment Agency/Executive Search
Energy Consultant
Ergonomic Consultant
Evaluator
Event/Party/Meeting Planner
Executive Coaching Services
Exhibit Designer
Expert Witness
Facilities Manager
Fairs/Exhibitions
Financial Management Consultant
Fire Investigator
Fitness Instructions
Fitness Instructor/Personal Trainer
Fitness Studios
Food Bank
Forensics Investigator
Foundations
Fraternal Org
Freight Forwarder/Customs Broker
Fundraising Consultant
Gardens
Golf Instructions
Goodwill
Grant Writing Services
Graphic Design
Group Homes for Children
Group Homes for IDD
Guidance Counselor
Handwriting/Document Analysis
Head Start
Historical/Preservation Society
Hoarding Assistant Services
Home Health – Mixed Care
Home Health – Non-Skilled Care
Home Health – Respite Care
Home/Personal Organizer
Homeless Shelters & Battered
Homeless Shelters & Battered Person's Shelters
Homeowners Associations, PUD, Master Communities
Hospice
Hospitality Management Services
Hotel Management
Housing Authority
Human Resource Consultant
Independent Living for IDD
Indoor Cycling Instructions
Insurance Inspector/Auditor
Interior Design
Interpreter/Translator
Inventory Services
Job Training/Sheltered Workshop
Junior League
Landscape Design
Librarian
Library
Life Coach
Lighting Design Consultant
Lobbyist
Mailing Services
Management Consultant
Manufacturer Representative
Marketing Consultant
Martial Arts Studios
Meals on Wheels
Media Consultant
Mediator
Mental Health Advocacy
Mental Health Residential
Mental Health/Case Manager
Mortgage Field Inspector
Municipal Consultant
Museum
Museums
Music and Sound Design Consultant
Non-Profit Advocacy & Consulting
Nonprofit & Social Service Organizations
Nonprofit – Not otherwise classified
Nonprofits – Not otherwise classified
Notary
Occupancy/ Condition Inspections
Outsourcing Consultant Paralegal
Park Management Services Payroll
Performance Art Group
Person's Shelters
Personal Trainer
Personal Training Studios
Pet Sitter
Photographer/Videographer
Polygraph Operator
Premium Finance Company
Print Broker
Private Investigator
Private School
Private Schools
Process Server
Processing Services Personnel
Professional & Trade Associations
Project Management
Promotional Services
Property Manager
Property Preservation Services
Public Record Search
Public Relations Consultant
Publisher
Real Estate Agent/Broker
Real Estate Appraiser
Recovery Meetings
Referees and Other Sports Officials
Registered Agent Services
Relocation Services
Rescue Mission
Reserve Study Consultant
Resume Service
Risk Management Consultant
Safety Council
Safety/Security Consultant
Seminar Instructor
Senior Center
Service Contract Administrator
Services Actuarial/Statistical Consultant
Social Clubs
Social Security Representative
Social Service Organizations – Not otherwise classified
Social Worker
Special Event: Concerts & Comedy Shows
Special Event: Conferences
Special Event: Farmers Markets
Special Event: Festivals
Special Event: Parades
Special Event: Special Events – Not Otherwise Classified
Special Event: Sporting Event
Special Event: Weddings
Speech Therapist
Spin Studios
Sport Clubs
Sports Associations
Sports Camps/Clinics
Sports Coach
Sports Facilities
Sports Franchises
Sports Instructor
Sports Leagues
Sports Leagues Camps Clinics
Sports Special Events
Sports Tournaments
Substance Abuse – Outpatient Only
Supply Chain Consultant
Teacher
Technology Services
Telecommunications Consultant
Thrift stores
Trade Associations
Traffic/Parking Consultant
Training Specialist
Transcription/Stenographer Services
Travel Agent
Trustee
Tutor
Umpires
United Way
Urban League
Urban Planning Consultant
Utility Water and Sewer Districts
Visitor Center
Vocal Coach
Wedding Planner
Wind Mitigation/4-Point Consultant
YMCA’s
YWCA
Yacht Clubs
Yoga & Pilates Studios
Yoga Instructor
Youth Association
Zoo's
ALL OTHER PROFESSIONAL SERVICES AND PROFESSIONS
Describe Your Operations, Products and Services:
(Required)
Please provide a description with a minimum of 10 words.
Applicant is a New Entity with No Prior Insurance Coverage
(Required)
Yes
No
How many years of experience in the industry do you have?
(Required)
Year business established:
(Required)
Applicant Has Experienced a Loss In the Last Five Years for a Coverages Being Requested
(Required)
Yes
No
Applicant Has Been Involved in Bankruptcy, Criminal or Civil Proceedings
(Required)
Yes
No
Applicant Has Had Insurance Denied, Cancelled, or Non-Renewed by an Insurance Company in the Last 5 Years for a Coverage Being Requested
(Required)
Yes
No
If you services require a license, do you have a valid license?
(Required)
Yes
No
N/A (License is not required)
Staff are Trained in Non-Violent Crisis Intervention and De-Escalation Procedures
(Required)
Yes
No
Insured has Detailed Procedures in Hiring Including Verifying the License is Current and has Never Been Suspended or Revoked
(Required)
Yes
No
Have Claims, Allegations, or Charges of Abuse, Molestation or Sexual Misconduct Been Made Against or on Behalf of the Applicant?
(Required)
Yes
No
Applicant has Formal New-Hire Screening Process
(Required)
Yes
No
Process Encompasses Criminal Background Checks, National Sex Offender Registry Search, Verification of Personal References, and Interviews
(Required)
Yes
No
Applicant Has a Formal Written Abuse Policy
(Required)
Yes
No
Policy Prohibits One-On-One Contact, Identifies Grooming Behaviors, and Outlines Reporting Procedures if Abuse is Suspected
(Required)
Yes
No
Applicant Has a Written Response Plan in Place for Handling Allegations of Abuse Including Dealing With Employees, Victims, Parents and Authorities
(Required)
Yes
No
How many staff members (including owners, W-2 employees, and 1099 subcontractors) do you have?
(Required)
About the participants of your programs
How many participants are aged 12 and under?
(Required)
How many participants are aged 13-15?
(Required)
How many participants are aged 16-18?
(Required)
How many participants are over age 18?
(Required)
Average Number of students per day:
(Required)
Any volunteers? If yes how many. If none enter "0":
(Required)
Due to the nature of your operations, we require an additional SAM Insurance Supplemental application to be completed in order to secure SAM quotes for the risk presented. Click “Submit” and you will be redirected to a form you need to fill out so we can work on the insurance quotes for you. If you have any questions, call 877-239-0067.