Business

General Information

Date Insurance Needed*

Owner(s) name(s) and Date of Birth(s):*

Ownership Percentage per owner:*

Business Name:*

DBA:

Main Contact Phone Number:*

Main Contact Email Address:*

Mailing Address:*

Street Address Address Line 2 City State ZIP Code

Years Experience in Industry:*

Please enter a number from 1 to 99.

FEIN*

Entity Type*

Sole Propiertorship/Partnership
LLC/LLP
Incorporation

Business Website:

Property & Liability

Description of Operations:*

Tell us about your company.

Location Address:

If different from mailing address.

Year Building Constructed:*

Occupied Square Footage:*

Please enter a number from 1 to 99999.

Liability Limit (typically 1 mil/2 mil)*

Tenants and Improvements:*

Please enter a number from 0 to 1000000.

$ value of tenant improvements

Business Property/ Equipment:*

Please enter a number from 0 to 1000000.

$ value of business property

Deductible Amount 1k, 2.5k, 5k?*

Main Source of Sales:

Any major business exposures?

Any Prior Losses?

If yes, please provide date of loss and details.

Estimated Gross Annual Sales:*

Please enter a number from 0 to 10000000.

Any Additional Coverage Desired?

Any Burglar or Fire Alarm/ What kind?*

Please List Your Curent Insurer:

Please attach current Dec Page

Max. file size: 128 MB.

Current Policy Expiration Date:

Current Annual Premium:

Special Notes or Circumstances:

Roof type*

Frame type

Electrical type

Central Alarm?

Yes
No
Unknown

Local Alarm?

Yes
No
Unknown

Sprinklered?

Yes
No
Unknown

Smoke Detectors?

Yes
No
Unknown

Exposures

Officers/Executives*

Yes
No

Additional Employees*

Yes
No

# of Full Time Employees*

Please enter a number from 0 to 1000.

# of Part Time Employees*

Please enter a number from 0 to 1000.

Total Estimated Payroll, Excluding Officers ($)*

Property Information

Property Occupancy*

Owned
Leased

Total Building Square Footage

Please enter a number from 1 to 100000.

Construction Type

Frame
Joint Marsonry
Steel
Other

Do other companies share building?

Yes
No

Building Security*

Yes, local alarm only
Yes, central alarm monitoring system
None

Fire Sprinkler System*

Yes
No

Distance to Nearest Fire Hydrant (feet)

Distance to Nearest Fire Station (miles)

Operations

Estimated Value of Business Property ($)

Equipment, computers, furniture, etc.

Estimated Value of Capital Improvements ($)

Office build out expenses, permanent fixtures installed, interior renovations, etc.

Insurance

Currently Insured*

Yes
No

Name of Current Carrier*

Policy Expiration Date*

Number of Claims in Last Five (5) Years*

0
1
2
3

Has policy ever been cancelled or non-Renewed In last five years?*

Yes
No

Type(s) of Insurance Coverage Needed:*

General Liability Coverage
Commercial Auto Coverage
Building Coverage
Business Property
Umbrella/Excess Liability Coverage
E&O/Professional Liability

Check all that apply.

Additional Interests

Will you need certificates of insurance provided to others?*

Yes
No

Landlord, mortgagee, or vendors that require to be a certificate holder.

Additional Notes/Coments

Please provide any additional details that may help us in providing you an accurate proposal.