Hudson Valley Business Insurance

Business Owners Insurance Request Form

Owner's Name *

Title

Email *

Phone *

Business Information

Business Name *

Business Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Webpage

FEIN/TAX ID Number

Company Size *

Type of Business

Years of Experience

Annual Sales for the Business

Business Policy Attachment

List Any Additional Location Address:

Have you ever had an insurance policy non-renewal, cancelled, or declined?

Have you ever been convicted of a crime of fraud, bribery, or arson?

Any bankruptcies, tax or credit liens?

Are there any additional insured's?

Coverages

Select desired coverage's below

General Liability Coverage

Annual Gross Receipts:

Total Number of Employees:

Annual Payroll:

Are subcontractors being used? What are their duties and how much do you spend on subcontractors annually?

Please describe the business:

Any foreign operations?

Is the business currently insured?

Any claims in the last 5 years?

Is a Wavier of Subrogation or Additional Insured's needed to be listed?

Do you lease space to others?

Property Coverage

Is the entity the building owner or tenant?

What year was the building built?

Construction type of building and roof?

Square footage of building

Does it have a monitored burglar or fire alarm?

Does the building have a sprinkler system?

How much would it cost to replace all the property inside the building?

Is any space leased out?

Are tenants you lease to required to list you as additional insured on their insurance?

Please describe any property claims in the last 5 years.

Commercial Auto Coverage

How many vehicles do you have?

Do employees take any vehicles home?

Garage Locations

Copy of Driver's list (include names, date of birth and driver license numbers), Copy of Vehicles List: Year, Make, Model and VIN#.

Description of what vehicles are used for:

Describe any auto claims in the last 5 years:

Umbrella Coverage

Do you have a commercial umbrella?

How much coverage do you think you need?

Workers Compensation Coverage

List Owners and Payroll for each:

List of Employees with Annual Payroll and Each Employees Occupation and Duties:

Do you use subcontractors? if Yes, What percentage of Annual gross income is spent on subcontractors?

Have you had any claims? If Yes, Please give Description:

ADDITIONAL INFORMATION TO INCLUDE:

OPTIONAL: