Contact Information
Before we talk about insurance, please tell us the best ways to reach you.
Name of Primary Contact
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Can we send text messages to this phone number?
*
Yes
No
How did you hear about us?
*
Referred by someone
Google/Online Search
Social Media
I was contacted by your agency
Other
GREAT! We LOVE referrals! Who referred you to us?
*
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Types of Commercial Insurance
Please select the types of commercial insurance we can help you with.
Policy Types:
*
Commercial Auto
Commercial Property
Commercial General Liability
Commercial Umbrella
Workers Compensation
Other
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General Business Information
Business Name
*
Business Entity Type
*
Please Select
Sole Proprietorship
Partnership
LLC
S-Corporation
C-Corporation
Trust
Other
Business Website:
SSN associated with business
FEIN
Please list all business owners:
*
Below, please provide the full name, residential address, and date of birth for at least one LLC member/corporate officer/individual owner. This is used by some carriers to apply up to a 15% credit on quotes.
*
Annual Gross Sales:
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% of sales to commercial customers
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(commercial customers = other businesses)
Number of Employees
*
Total Annual Payroll
*
Are there any additional DBA business names?
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Yes
No
Please list all DBA names and explain their usage:
*
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General Business Information
Date business began:
*
/
Month
/
Day
Year
Doesn't have to be exact
Years of industry experience:
*
Please describe the nature of the business:
*
Primary Business Location
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Are there additional business locations?
*
Yes
No
Please list all additional business locations below:
*
Does the business use subcontractors?
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Yes
No
Total annual cost of subcontractors:
*
Do you collect certificates of insurance from all subcontractors?
*
Yes
No
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Commercial Auto
Does your business currently have Commercial Auto Insurance?
*
Yes
No
Please explain below why you do not currently have Commercial Auto Insurance:
*
If possible, please upload a copy of your current Commercial Auto Insurance policy:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Current Insurance Carrier:
Current Expiration Date:
/
Month
/
Day
Year
Date
Number of years with current insurance carrier
*
Has your business filed any Commercial Auto Insurance claims within the past 3 years?
*
Yes
No
Please provide details regarding those claims (approximate dates, cause of damage, approximate amount paid, etc.):
*
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Commercial Auto
Please select your desired coverage amounts below.
Combined Bodily Injury/Property Damage Liability
*
Please Select
$1,000,000 CSL
>$1,00,000 CSL
As an agency, we do not write limits less than $1,000,000 Combined Single Limit (CSL) of Liability
Uninsured/Underinsured Motorists
*
Please Select
$100,000/$300,000
$250,000/$500,000
$500,000/$1,000,000
$1,000,000/$2,000,000
If you aren't sure, feel free to go with the pre-selected amount.
Medical Payments
*
Please Select
$1,000
$2,000
$5,000
$10,000
If you aren't sure, feel free to go with the pre-selected amount.
Please list all vehicles:
*
Please list all drivers:
*
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Commercial Property
Does your business currently have Commercial Property Insurance?
*
Yes
No
Please explain below why you do not currently have Commercial Property Insurance:
*
If possible, please upload a copy of your current Commercial Property Insurance policy:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Current Insurance Carrier:
Current Expiration Date:
/
Month
/
Day
Year
Date
Number of years with current insurance carrier
*
Has your business filed any Commercial Property Insurance claims within the past 3 years?
*
Yes
No
Please provide details regarding those claims (approximate dates, cause of damage, approximate amount paid, etc.):
*
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Commercial Property
Business Personal Property:
*
This is the dollar amount of property/contents owned or leased by your business (excluding real property)
Business Income / Extra Expense:
*
Please Select
6 months of Revenue
12 months of Revenue
18 months of Revenue
24 months of Revenue
This coverage pays for non-ordinary expenses resulting from business disruption during a claim. If you aren't sure, feel free to go with the pre-selected amount.
Business Inventory:
*
This is coverage for items, component parts and raw materials that a company either sells or uses in production.
Equipment used at job sites:
*
This is coverage for tools and equipment used on job sites away from the locations owned or operated by the business.
Buildings
Using the section below, please separately list & describe each building that needs to be insured.
Does the business own any buildings that need to be covered by this policy?
*
Yes
No
Using the section below, please separately list & describe each building that needs to be insured.
*
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Commercial Liability
Does your business currently have Commercial Liability Insurance?
*
Yes
No
Please explain below why you do not currently have Commercial Liability Insurance:
*
If possible, please upload a copy of your current Commercial Liability Insurance policy:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Current Insurance Carrier:
Current Expiration Date:
/
Month
/
Day
Year
Date
Number of years with current insurance carrier
*
Has your business filed any Commercial Liability Insurance claims within the past 3 years?
*
Yes
No
Please provide details regarding those claims (approximate dates, cause of damage, approximate amount paid, etc.):
*
Please select the types of Commercial Liability coverage you need:
*
General Liability
Professional Liability (E&O)
Directors & Officers Liability
Employment Practices Liability
Liquor Liability
General Liability Limits:
*
Please Select
$100,000 / $300,000
$250,000 / $500,000
$500,000 / $1,000,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$2,000,000 / $4,000,000
If you aren't sure, feel free to go with the pre-selected amount.
Professional Liability (E&O) Limits:
*
Please Select
$100,000 / $300,000
$250,000 / $500,000
$500,000 / $1,000,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$2,000,000 / $4,000,000
If you aren't sure, feel free to go with the pre-selected amount.
Directors & Officers Liability Limits:
*
Please Select
$100,000 / $300,000
$250,000 / $500,000
$500,000 / $1,000,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$2,000,000 / $4,000,000
If you aren't sure, feel free to go with the pre-selected amount.
Employment Practices Liability Limits:
*
Please Select
$100,000 / $300,000
$250,000 / $500,000
$500,000 / $1,000,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$2,000,000 / $4,000,000
If you aren't sure, feel free to go with the pre-selected amount.
Liquor Liability Limits:
*
Please Select
$100,000 / $300,000
$250,000 / $500,000
$500,000 / $1,000,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$2,000,000 / $4,000,000
If you aren't sure, feel free to go with the pre-selected amount.
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Commercial Umbrella
Commercial Umbrella Insurance provides an extra layer of liability protection by covering costs that go beyond your other liability coverage limits
Does your business currently have Commercial Umbrella Insurance?
*
Yes
No
If possible, please upload a copy of your current Commercial Umbrella Insurance policy:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Current Insurance Carrier:
Current Expiration Date:
/
Month
/
Day
Year
Date
Number of years with current insurance carrier
*
Has your business filed any Commercial Umbrella Insurance claims within the past 3 years?
*
Yes
No
Please provide details regarding those claims (approximate dates, cause of damage, approximate amount paid, etc.):
*
Desired Excess Liability Limits:
*
Please Select
$500,000 / $1,000,000
$1,000,000 / $2,000,000
$2,000,000 / $4,000,000
$5,000,000 / $10,000,000
If you aren't sure, feel free to go with the pre-selected amount.
Desired Retained Limit:
*
Please Select
$500
$1,000
$2,500
$5,000
$10,000
$25,000
This works like a deductible
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Workers Compensation
Does your business currently have Workers Compensation Insurance?
*
Yes
No
Please explain below why you do not currently have Workers Compensation Insurance:
*
If possible, please upload a copy of your current Workers Compensation Insurance policy:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Current Insurance Carrier:
Current Expiration Date:
/
Month
/
Day
Year
Date
Number of years with current insurance carrier
*
Has your business filed any Workers Compensation Insurance claims within the past 3 years?
*
Yes
No
Please provide details regarding those claims (approximate dates, cause of claim, approximate amount paid, etc.):
*
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Workers Compensation
Would you like to include the business owners/officers in this Workers Compensation coverage?
*
Yes, include owners/officers
No, exclude owners/officers
Current Experience Modification:
(if known)
Please indicate the number of employees and the percentage of total payroll for each job classification below.
*
Number of Employees
Percentage of Total Payroll
Clerical Staff
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Service Staff
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Technical Staff
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Management Staff
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Would like to include coverage for Employer's Liability?
*
Yes
No
Employer's Liability Coverage Limits:
*
Please Select
$100,000 / $500,000 / $100,000
$500,000 / $500,000 / $500,000
$1,000,000 / $1,000,000 / $1,000,000
If you aren't sure, feel free to go with the pre-selected amount.
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You selected "Other" as the type of insurance you need.
Please tell us below what kind of insurance you're looking for.
*
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Comments
Please use the box below to provide any additional details that may help us find the best insurance options for your business.
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