OSI Intro Commercial Ins Intake Form

GENERAL INFORMATION

Let's get to know each other!
Name of OSI Producer Who Contacted You:
Name of Business or Legal Entity: *
DBA (IF APPLICABLE)
Principal Contact: *
Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code
Is the Mailing Address the Same as the Business Address?
Business Address (If different from Mailing Address)

Street Address

Street Address Line 2

City State

Zip Code
Phone Number

Area Code Phone Number
Website:
www.example.com
Email Address:
example@example.com
Briefly Describe Your Business (What do you do?):
Years In Business:
Years of Experience in the Field:
Estimated Annual Revenue:
Does your business have more than one location?

Yes No
How many locations do you have?
Desired Effective Date:

Month Day Year
Date
Business Type:

Corporation Partnership Individual LLC
FEIN:
Federal Employer Identification Number
PRESENT OR PRIOR CARRIER INFORMATION

Please use most current years information
Insurance Carrier Name
What is the total amount you pay for your business insurance annually?
PROPERTY INFORMATION

Location 1
Is the address for location 1 the same as the Business Address listed above?
Location 1 Address *

Street Address

Street Address Line 2

City State

Zip Code
Is this location an owned condo?
Year Built
Construction

Frame Brick Cement /Steel Free Standing Building Strip Mall Shopping Mall
Square Footage
Number of Stories
Replacement Value
(if owned by you)
Are you:

A tenant in the building? An owner of the building?
If you are a tenant, does your landlord require a certificate of insurance?
Name of Landlord
Address pf Landlord

Street Address

Street Address Line 2

City State

Zip Code
Sprinkler System

Yes No
Security System

None Central (monitored by professional service) Local (authorities NOT automatically notified. bell, siren, or a strobe light.)

Year of Updates

	Year Updated
Electrical
Roof
HVAC
Plumbing

Contents Value

inventory, contents, property of others, furniture & fixtures, rental equipment
Average Contents Limit at this Location
Day to day average content value
Maximum Value (Peak Season) at this Location
If seasonally your value fluctuates higher than the average above, please include.

Liability Info
Do you rent or demo any Products at your store(s)? *
Please Complete the Following Table Based on the Products (Hard Goods) You Sell/Rent
Do you offer any recreational activities to customers? (Ex: Bike Tours, Guided Fishing, etc)? *
Please Complete the Following Table Based on the Activities you Provide

Employee Info
Number of Full Time Employees
Number of Part Time Employees
Other Insurance Needed

Please Select the Additional Lines of Insurance You Would Like Quoted
Additional Coverage Requested

Workers’ Comp Business Auto Umbrella Cyber Liability Professional Liability (E&O) Crime (Employee Theft, Forgery, etc)
Loss History
Have you had any prior claims in the last 10 years?
Please upload loss runs in upload section below.
Please upload supplemental documents you would like to share for convenience. (Ex: Current policy Dec Pages, Spreadsheet of Locations/Schedule of Values, Loss Runs, Previously Completed Applications, etc.)
FRAUD NOTICE STATEMENT
NOTICE TO 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 MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.”
Please review your rights to Privacy in our Terms and Conditions *
Name

First Name Last Name
Signature *

By signing, I hereby declare that the above provided information is accurate to the best of my knowledge. I have read the terms and conditions regarding the privacy and handling of my personal information provided within this application. Clear
Date *

Month Day Year
Date
THIS IS AN APPLICATION FOR INSURANCE. THIS IS NOT A BINDER OF INSURANCE.
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GENERAL INFORMATION

PRESENT OR PRIOR CARRIER INFORMATION

PROPERTY INFORMATION

Contents Value

Contents Value

Contents Value

Liability Info

Employee Info

Other Insurance Needed

Loss History

FRAUD NOTICE STATEMENT