Commercial Insurance Starter Application

Commercial Insurance Intake Form
Tell Us About Your Business
Your Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Business Name*
Type of Organization
Select from dropdown
Years in business
Additional Owner or Contact Name (if applicable)

First NameLast Name
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Industry
What type of business are you in?
Gross Annual Receipts
Annual Revenue before any expenses paid
Total Annual Payroll
in USD
Number of Employees
Do you use independent contractors (subcontractors)?

YesNo
If yes: Total Subcontractor Payroll
in USD
Type of work subbed out
Do you collect Certificates of Insurance (COI's) from subcontractors?

YesNoSometimes
Your Location
Property Coverage Needed? This may includes building, equipment, tools, electronics, business personal property.

YesNo
Do you own or lease your building?

OwnLease
Estimated Replacement Value
Estimated cost to rebuild. This can also be tenant improvements only if leasing. Feel free to share lease for review if unsure.
Construction Type
Business Personal Property
Value of tools, equipment (except mobile), office furniture & supplies
Total Square Footage
Year Built
Roof Type
Year Last Updated
Fire/Burglar Alarms & Sprinklers (select all that apply)

Local Fire AlarmCentralized Fire AlarmConnected Fire AlarmLocal Burglar AlarmCentralized Burglar AlarmPolice Connected Burglar AlarmFull SprinklersPartial Sprinklers
Additional Structures or Locations?
Any Mobile or Specialty Equipment?
You may upload equipment schedules below if multiple equipment
Your Transportation
Does your company own vehicles?

YesNo
Year
You may upload schedules or current policy below if multiple vehicles
Make & Model
VIN (If you have it handy)
Additional Equipment Attached?
Any additional vehicles?

YesNo
Year
You may upload schedules or current policy below if multiple vehicles
Make & Model
VIN (If you have it handy)
Additional Equipment Attached?
Coverage & History
Coverages Requested

Workers' CompensationCommercial General LiabilityBusinessowners Package (BOP) - Combines GL & PropertyCommercial PropertyCommercial AutoInland MarineLet's talk Ancillary Coverages (Cyber, EPLI, Pollution, E&O)I don't know - let's talk!
Current Carrier(s)?
Expiration Date

MonthDayYear
Date
Any claims in the last 5 years?
On any lines of coverage. Underwriters may request 3-5 years of loss runs prior to quoting or issuance
Has coverage been cancelled or non-renewed 5 years?
On any lines of coverage. If yes, please explain
Any bankruptcy, judgments, or liens in past 5 years?
If yes, please explain
Additional Description of Operations or Notes that will help us best serve you?
Please give a description of the services you provide or the work you do. If you have additional notes to share, you may use this space as well
Everything that I have stated in this application is true & correct to the best of my knowledge. I understand that information submitted will be verified during the rating process and that additional information may be requested prior to quote or coverage issuance.
Date

MonthDayYear
Date
Applicant Signature

Clear
File Attachments (if applicable)

Current Policies, Declarations Pages, or Renewal Proposal. If you have property, auto, or equipment schedules, you may also upload them here.
Cancelof
Should be Empty:

Commercial Insurance Intake Form

Tell Us About Your Business

Your Location

Your Transportation

Coverage & History