*Indium Commercial Submissions

Your Name

First NameLast Name
Your Email
example@example.com
Your Phone Number
Please provide a text enabled phone number if you would like to opt-in to texting about this inquiry.Format: (000) 000-0000.
By checking this box, I consent to receive text messages related to insurance inquiries, quotes, policy, and service updates from Indium. You can reply STOP to opt out at any time. Messages and data rates may apply. Message frequency will vary. Reply HELP to (614)942-1460 for assistance. For more information, refer to our Privacy Policy and SMS Terms and Conditions on our website
Agency Name
Did you submit this previously as a Market Question?
Insured Business Name
Effective Date

MonthDayYear
Quote Need by Date

MonthDayYear
Industry/Sector:
You MUST SELECT a NAIC Code/pre-populated answer
NAIC Industry/Sector:
You must select a valid NAICS

If you have trouble finding a NAICS, we recommend these resources;
NAICS to SIC crosswalk
US Census Bureau's NAIC Manual

If you are looking for long-term solutions for NAICS, please connect with our Membership team. We have numerous companies that we partner with and are co-op eligible.
I am not able to find an accurate NAIC. I understand I may be subject to a pass through report fee of $8 should disagreements arise
Target Premium
If you do not know an exact target, please include the insured's current premium
Market Status
Select All You're Interested In:

Other
This insured is eligible for Digital Brokerage Submissions. Indium has partnered with 14 carriers across 250+ markets to support agencies on small commercial ($10K or less target premium). To read more about this, please check out this page. Carrier(s) will appear below if this is a prioritized industry/sector for them. Agencies are not required to participate. This is an opportunity to work more closely with the carriers to assess the viability of an appointment; if an agency declines, standard submission guidelines will be followed.

Please select ONLY 1 carrier from below if you would like to proceed with a Digital Brokerage Submission:
Hiscox
I understand that by selecting numerous options (with the exception of Forge for Commercial Auto), this submission will be ineligible for the Digital Brokerage and the Solutions Advocacy team will proceed with standard submission guidelines.
Hidden (DB Calculation)
Please attach Acords, an Exposure Workbook or SOVs for applicable lines of business

Cancelof
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Commercial: Contact & Basic Information
Primary Contact for Insured

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insured Website
if the insured does not have one, please enter "www.none.com"
Business Type

🚨 Loss History ☢️

***Agencies that are unresponsive after submission or have critically low bind rates will be required to provide loss history upon submission to improve efficiency for fellow agency members, carriers, and the Indium team.*** Whether required or not, loss history helps expedite a submission.
Upload Loss Runs or No Known Loss Letter

Cancelof
OR add Loss History Individually
Claim(s)
Has any product, work, accident, or location been excluded, uninsured, or self insured from any previous coverage?
Was tail coverage purchased under any previous policy?

Please share any additional details/description of operations
Should be Empty:

Commercial: Contact & Basic Information

🚨 Loss History ☢️

OR add Loss History Individually