Business Owner's Policy
Insurance Application
Firm Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Contact
Title
Email
example@example.com
Website
Phone Number
Please enter a valid phone number.
Date firm commenced operations
-
Month
-
Day
Year
Date
Federal Tax ID #
Firm Type
Corporation
LLC/LLP
Partnership
Other
If you have been in business fewer than 3 years, please attach leadership resumes.
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Who is your current Insurance Company?
Carrier for General Liability Insurance , BOP, Property or Auto
Have you had any losses or claims in the last 5 years?
Yes
No
If yes, please provide loss runs (a statement of your actual loss history provided by your insurance carrier).
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Description of Operations
Do you have foreign operations?
Yes
No
If yes, please explain:
Number of Owners
Number of Employees
Annual Gross Revenues
Annual Payroll
Coverage Effective Date
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Do you have more than one name for your business or multiple names? If yes, please provide a description of operations for each:
Do you do construction management or design build? If so, please explain.
What percent of your receipts are from construction management or design build?
Professional Liability Insurance Information:
Carrier
Policy #
Effective date
Limit
Very Satisfied
PLI
How many of your employees are off premises more than 10% of the time?
Coverages
General Liability Limit
$500k/ $1 Mil
$1 Mil/ $2 Mil
$2/ Mil/ $4/ Mil
Do you need Umbrella coverage?
Yes
No
Umbrella Limit?
Do you want Employee Benefits Liability Insurance?
Yes
No
Employee Liability Retro Date?
Do you need limits for any of the following coverages?
Limit $
Valuable Papers
Employee Dishonesty
Accounts Receivable
Field Equipment
If you need Field Equipment Coverage, please provide a complete list of field equipment with values:
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Non-Owned / Hire Auto Liability
Yes
No
Hired Auto Physical Damage
Yes
No
Hired and non-Owned Auto Questions:
If you need Non-Ownerd / Hired Auto coverage please answer the question below:
Annual cost of hire/rental of autos (if any):
Number of employees that drive their own cars for company business on a regular basis:
If any, please provide us with a drivers list to include full name, date of birth, license number and state.
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Do you check each driver's motor vehicle record prior to hire and/or annually thereafter?
Yes
No
Do you have a procedure for verifying employees' personal auto insurance?
Yes
No
Do you require minimum limits of liability on employees' personal insurance?
Yes
No
If yes, what limit?
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Physical Location Information
If you have more than one location complete an additional location questionnaire for each location.
Location # 1 of
locations.
Address
Street Address
County
City
State / Province
Postal / Zip Code
Construction Type
Type of Occupancy
Tenant
Owner Occupied
Year Built
If year built is more than 30 years ago, supply the year of the most recent updates:
Year
Electrical
Plumbing
Roof
Heating
Does the building have a functioning sprinkler system?
Yes
No
Building Information
#
Total Square Footage of Building?
Number of Stories?
Square Footage you Occupy?
What Floor(s) are you located on?
Distance to Fire Station
Feet from the Fire Hydrant
Are there smoke detectors?
Yes
No
Dead bolt locks in use?
Yes
No
Theft Alarm
Local
Monitored
Fire Alarm
Local
Monitored
Do any of the following business types reside in the building? Please check all that apply.
Yes
Manufacturing
Restaurant
General Warehouse
Offices
Retail
Bar or Tavern
Limits requested if insuring the building
$
Building Limit
Business Contents
Deductible
Computer Hardware Equipment Limit
Computer Software Equipment Limit
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Applicant's Name
Title
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: