Commercial Insurance Proposal Request

Commercial Insurance Proposal Request
Proposed Effective Date:
MM/DD/YYYY
Business Name: *
DBA (if applicable):
Principal Contact Full Name:*

First NameLast Name
Primary Phone*

Area CodePhone Number
Business Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Tax ID:
CorporationLLCPartnershipIndividualNot-For-ProfitOther
Ownership %: (List each owner and percentage of ownership)
Primary owner's experience in industry
Inspection Contact Name:
Phone Number

Area CodePhone Number
Email
example@example.com
Accounting Contact Name:
Phone Number

Area CodePhone Number
Email
example@example.com
Description of Operations
Year Business was Established:
eg. 1995
Years of Owner’s Experience in Industry:
eg. 5 years
Estimated Gross Annual Revenue:
Estimated Gross Annual Payroll:
Total Number of Employees
How many Full Time
How many Part Time
Name of Current Liability Insurance Carrier:
Policy Expiration Date:
Retroactive Date: (if any):
Current Liability Limits:
Name of Current Property Insurance Carrier:
Policy Expiration Date:
Current Property Limits:
Commercial AutoEmployers Practices LiabilityBondWindstormBusiness Owners Policy (BOP)Product LiabilityCommercial General LiabilityCyber LiabilityProfessional LiabilityCrimeData Breach LiabilityDirectors & Officers LiabilityOther
Occurrence: $1,000,000 / Annual Aggregate: $2,000,000Occurrence: $2,000,000 / Annual Aggregate: $4,000,000Occurrence: $3,000,000 / Annual Aggregate: $6,000,000
YESNO
YESNO
YESNO
YESNO
PROPERTY DETAILS:
YESNO
If yes, please state total Square Feet of Building:
If you are a Tenant, please state Total Square Feet of your leased space:
PROPERTY COVERAGE & LIMITS DESIRE:
Building Limit:
Business Personal Property (BPP) Limit:
Business Income Limit:
Stock Limit:
Spoilage Limit:
Equipment Breakdown Limit:
Ordinance or Law Coverage:
AOP Deductible:
Sub-limit for Theft Coverage is available ONLY with a Central Station Burglar Alarm System
Premises Location & Building Information:
Location 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Building Construction Type:
Number of Stories:
% Sprinklered
YESNO
Year Built:
State Year of All Building Updates:

Year Renovated (Mandatory if building is greater than 10 years old):
Roof
Electrical
Plumbing
Heating/AC
BuildingSecurity Fire AlarmCentralStation Burglar AlarmNone
YESNOBatteryHardwired
Commercial Auto
Driver

First NameLast Name
Date of Birth

MonthDayYear
Date
Drivers License #
Year/Make/Model
VIN
Additional drivers and vehicles or coverage needs . . .
Should be Empty:

Commercial Insurance Proposal Request

Commercial Auto