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Commercial Insurance Application
General Business Information
What is the full name of your business?
Submitted By:
*
YOUR First Name
YOUR Last Name
Your Email
*
example@example.com
Your DOB
-
Month
-
Day
Year
Date
Your Phone
*
Please enter a valid phone number.
How did you hear about us?
*
Referral
Google Search
Social Post
Other
Referred By Person info: Please put their name and email below so we can thank them!
First Name
Last Name
Referred By Email
example@example.com
Prospect Information
Company Name
*
Main Contact Name
First Name
Last Name
Role
Role / Position at the Company
Main Contact Email
example@example.com
Company Phone Number
Please enter a valid phone number.
Company Website
If Applicable
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What Type of Policies Would You Like? (click all that apply)
Business Owners Policy (BOP)
General Liability
Worker's Compensation
Commercial Auto
Cyber Liability (Standalone)
Motor Truck Cargo
Misc. Professional Liabilty
Surplus Lines - Property
Surplus Lines - General Liability
Umbrella Liability / Excess Liability
Special Events
Business Information
FEIN#
Entity Type
*
Please Select
Association
Corporation
Individual
Non-Profit
Limited LIability Company
Partnership
Trust
Year Business Established
*
Industry
NAICS Code
If Known
Years of Industry Experience
*
What Does Company Do?
General Overview
Number of Full Time Employees
Number of Part Time Employees
Number of Subcontractors
Annual Payroll
For Entire Payroll
Worker's Comp Payroll Code
If Known
Gross Sales
Most Recent Year
Any 24 Hour Operations?
Yes
No
Hours of Operation
Amount of Business Personal Property Coverage
$ Amount
DOT #
If Applicable
If requesting COMMERCIAL AUTO, please include locations below where vehicles are garaged
Garaging Address
How Many Total Vehicles
Include Cars, Trucks, Trailers, Etc.
Business Use Class
Service
Retail
Commercial
Other
Auto Liability Limit
$ Amount
How Many Cars
Cars Only
How Many Trucks
Trucks Only
Truck Body Type
Bus
Catering Truck
Mini Van
Pick Up
Step Van
Utility Van
Semi
Other
Gross Vehicle Weight (in lbs)
How Many Trailers
Trailers Only
Add Hired & Non-Owned Auto Liability Coverage?
Yes
No
Are Any of the Vehicles Leased to Others?
Yes / No
Radius Class
Please Select
Local
Intermediate
Long Haul
Percentage of Driving Under 50 Mile Radius
Percentage of Driving Within 51-200 Mile Radius
Percentage of Driving Within 201-500 Mile Radius
Percentage of Driving over 500+ Mile Radius
Do You Require MVR Verification for Drivers
Yes
No
Other
How Many Locations?
1
2
3
4
Other
If Multiple Locations, Please List Additional Locations Below:
Addresses of additional locations
Building Property Owned or Leased?
Owned
Leased
Subleased
If Owned, is there a mortgage and if so, who is lender?
Please answer both questions above
When Did You Purchase the Property?
Approximate Year
Total Building Square Footage
Entire Building SF
Occupied Square Footage
SF Business Occupies
Building - Year Built
Building - # of Stories
Construction Type
Frame, Masonry, Pre-Cast, etc.
Sprinkler System?
Yes
No
Other
Type of Smoke Detectors
Please Select
None
Wired
Battery
Hardwired with Carbon Monoxide Detector
Battery Operated with Carbon Monoxide Detector
Does Your Operation Have Rack Storage 12 Feet or Higher?
Yes
No
Any Alcohol Sales?
Yes
No
Who Manages the Property?
Self
Third Party Professional Property Management Company
None
Other
If 3rd Party Property Management Company, Name of Company
Name of the Property Management Company
Any Updates to Building (if owned)?
Heating, Plumbing, Electrical, Roofing, Etc.
Do You Have Coverage Currently?
*
Yes
No
If NO current insurance, please explain:
Reasoning: New Venture - Cancelled - Lapse - etc.
Current Insurance Carrier
*
Years with Current Carrier
# of Years
Current Insurance Premium
Current Insurance Expiration
-
Month
-
Day
Year
Date
If YES above, please attach your current declaration pages, loss runs, and any other insurance documentation
Browse Files
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Any Losses? If Yes, explain in "Other"
*
No
Yes
Other
Any Other Info We Should Know:
Additional File Upload
Browse Files
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Choose a file
Declaration Pages, Loss Runs, List of Commercial Vehicles / Drivers, etc.
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