Small Business

General Information
Who referred you to us?*
Fill in the name of the person who sent you our way
Name*

First NameLast Name
Title*
Title of the Contact Person listed above: Owner, Owner's Assistant, etc...
Legal Name of the Business*
Legal Name of the Business
Phone Number*
Please enter a valid phone number.
Fax*
Please enter a valid fax number.
Social Media*
@
Email*
example@example.com
Business Owners Full Name*

First NameLast Name
Business Location Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website*
Web URL goes here
Federal TAX ID*
EIN Number
Entity Type? (Corp, Sole Prop, LLC, etc.)*
Date business was started*

MonthDayYear
If New Venture, list prior experience*
Which State is the Business Registered in?*
Annual Gross Receipts Prior Year*
Annual sales before taxes and write offs
Gross Receipts Current Year*
Annual sales before taxes and write offs
Gross Receipts Projection Next Year*
Annual sales before taxes and write offs
Total Annual Payroll*
Combine payroll of W2, 1099, Part-Time & Full-Time workers
Number of full time employees*
List the job roles*
List the job roles of Part Time (PT) employees...
% of Work Subcontracted*
List the Number of 1099 Employees*
Verification of insurance required prior to work start date?*
Are you listed as an additional insured on their insurance policy?*
Owners Payroll*
List the number of owners*
Business Description (including industry type, typical services performed, clients served, products, etc.)*
Do you operate any other type of business or own any other building than listed on this form?*

YesNo
If Yes, please provide details:*
Contracting Operations
Do you have an attorney who evaluates your contracts?*

YesNo
If Yes, who is your attorney?*
If you don't have one, Type N/A...
Who has the authority to sign contracts on behalf of your business?*
Workers Compensation*

Location / Building Information
Do you own the office space?*

Yes, I bought the buildingNo, I am a tenant occupying a space owned by someone else
Do you need coverage for your office?*
You may need Liability, Property, or Contents coverage
Type of building you occupy (office, retail strip mall, industrial, etc.)*
Owner or Tenant?*
Sq Ftg You Occupy*
Stories*
Approx Year Built:*
Construction (Frame, Masonry, Noncombustible, Fire Resistive, etc.)*
% of Bldg Sprinklered*
If bldg over 30 yrs old, Year(s) Updated for Wiring, Heating, Plumbing, Roof*
Alarm? Burglar or Fire? Local or Central Station?*
Would you like Business Income & Extra Expense Protection?*
Workers Compensation*
Is this a Brand New Business Venture?*

YesNo

Insurance Carrier History
Have you had insurance coverage declined, cancelled or non-renewed during the last 3 years?*

YesNo
If yes, please provide the details: *
If you have been previously insured, who was the most recent insurance company?*
Have you had any previous insurance claims in the last 5 years?*
If Yes, please provide the details. If No, please type N/A...
Please attach a copy of your most recent insurance declaration page*
Copies of 5 year Loss Runs for each account you have such as General Liability, Commercial Auto, Excess Liability, Cargo, Workers Compensations, Etc.*
Property and General Liability*
Automobile*
Workers Compensation*
Umbrella*

Do you want Cyber Liability?*

YesNo

Do you want Property Insurance?*

YesNo

Property
Building*
Business Contents Replacement Value*
Building Improvements & Betterments*
Computer Value*
Computer Software (data & media)*
Other Property Used or Stored Off Premises (describe & value)*
Accounts Receivable*
Exterior Sign?*
Total Misc Mobile Tools & Equipment (max $,1000 value per item)*
Scheduled Mobile Equipment (for individual items exceeding $1,000 in value)*
Attach Schedule*
Do you rent or loan equipment to others?*

YesNo
If Yes, please provide equipment details:*
Contents may include, but is not limited to: Leasehold Improvements, Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, and Property of Others in Your Care. Please consult your lease requirements when choosing the coverage and limits for this location.

Do you want Crime Insurance?*

YesNo

Crime Insurance
Employee Dishonesty Limit*
401(k) Plan? If Yes, Plan Name *
Forgery/Alteration Limit*
Theft of Money (Inside/Outside)*
Computer Fraud Limit*
Each Occurrence Limit*
General Aggregate Limit (if other than 2x Occurrence)*
Fire Legal Liability Limit (if other than $50,000)*
Medical Payments Limit (if other than $5,000)*
Do you require subcontractors to have insurance, and do you obtain Certificates of Insurance?*

YesNo
PROPERTY | CRIME | GENERAL LIABILITY SECTION COMMENTS:*

Do you want Workers Compensation Insurance?*

YesNo

Workers Compensation

	Owner/Officer Name	Title	% of ownership	Duties (or indicate if inactive)	Annual Payroll	Include or Exclude Owners form Workers Comp coverage?
1
2
3
4
5

Are you interested in Business Auto Insurance?*

YesNo

Business Auto
Auto Liability (Combined Single or Split Limits)*
Uninsured / Underinsured Motorist Limit(s)*
Medical Payments*
Personal Injury Protection*
Comp Deductible*
Collision Deductible*
Towing & Labor (for private passenger vehicles)*
Rental Reimbursement*
If any owners / key employers have their personal vehicles on policy, please give their names and names of their spouses below.*
Do you rent vehicles for business use?*

YesNo
If Yes, # of days per year*
Do employees use personal vehicles for business?*

YesNo
If Yes, for what purposes?*
AUTO SECTION COMMENTS*
Vehicle Schedule
Upload Vehicle Schedule*
Driver Schedule
Upload Driver Schedule*

Acknowledged and agreed by client:*

Clear
Sub Agency

Are you in the Medical Spa Industry?

YesNo
Should be Empty:

General Information

Contracting Operations

Location / Building Information

Insurance Carrier History

Cyber Liability

Property

Crime Insurance

Workers Compensation

Business Auto

Vehicle Schedule

Driver Schedule

Other Coverage To Consider