Commercial Insurance Starter Application

1
Your Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Business Name* This field is required.
5
Type of OrganizationThis is how you're registered legally
Limited Liability Company (LLC)
Limited Liability Partnership (LLP)
Corporation
Sole Proprietor
Non-profit
Governmental Entity
Select from dropdown
6
Years in businessWhat year was this business been established?
7
Additional Owner or Contact Name (if applicable)
First Name
Last Name
8
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
IndustryTell us about the type of work you do?
What type of business are you in?
10
Gross Annual ReceiptsThis is the money in before any goes back out, such as labor, materials, fuel
Annual Revenue before any expenses paid
11
Total Annual PayrollThis is the total that you pay all employees (we'll get to subcontractors later)
in USD
12
Number of EmployeesHow many do you have on the payroll?
13
Do you use independent contractors (subcontractors)?This includes your 1099 contractors
Yes
No
14
If yes: Total Subcontractor Payroll
in USD
15
Type of work subbed out
16
Do you collect Certificates of Insurance (COI's) from subcontractors?
Yes
No
Sometimes
17
Property Coverage Needed?This may include building, equipment, tools, electronics, business personal property
Yes
No
18
Do you own or lease your building?
Own
Lease
19
Estimated Replacement Value This is the cost to rebuild the building, or your tenant improvements if a lease
Estimated cost to rebuild. This can also be tenant improvements only if leasing. Feel free to share lease for review if unsure.
20
Construction TypeWhat's it build out of?
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Fire Resistive
Modified Fire Resistive
21
Business Personal Property This is the contents within the building, such as all furniture, tools, stationary equipment, supplies
Value of tools, equipment (except mobile), office furniture & supplies
22
Total Square FootageHow big is your space?
23
Year BuiltWhen was it built?
24
Roof TypeWhat kind of roofing material does it have?
Asphalt shingles
Bitumen
BUR (Bitumen/Asphalt)
Green (Vegetative)
Membrane
Metal
Rubber
Wood
Other or Unknown
25
Year Last UpdatedWhen were updates last made, such as roofing, plumbing, electrical, or HVAC
26
Fire/Burglar Alarms & Sprinklers (select all that apply)
Local Fire Alarm
Centralized Fire Alarm
Connected Fire Alarm
Local Burglar Alarm
Centralized Burglar Alarm
Police Connected Burglar Alarm
Full Sprinklers
Partial Sprinklers
27
Additional Structures or Locations?Are there any other structures on the property you're responsible for? Do you have multiple locations?
You may also upload schedules below if you have multiple buildings or locations
28
Any Mobile or Specialty Equipment?
You may upload equipment schedules below if multiple equipment
29
Does your company own vehicles?If you have multiple vehicles, you can upload schedules or your policy at the end
Yes
No
30
Year
You may upload schedules below if multiple vehicles
31
Made & Model
32
VIN (If you have it handy)
33
Additional Equipment Attached?
34
Any additional vehicles?You may also upload schedules at the end
Yes
No
35
Year
You may upload schedules below if multiple vehicles
36
Made & Model
37
VIN (If you have it handy)
38
Additional Equipment Attached?
39
Coverages Requested
Workers' Compensation
Commercial General Liability
Businessowners Package (BOP) - Combines GL & Property
Commercial Property
Commercial Auto
Inland Marine
Let's talk Ancillary Coverages (Cyber, EPLI, Pollution, E&O, D&O)
I don't know - let's talk!
40
Current Carrier(s)?This is the current insurance company (or companies) that have your policies
41
Expiration Date
Date
Month
Day
Year
42
Any claims in the last 5 years?
On any lines of coverage. Underwriters may request 3-5 years of loss runs prior to quoting or issuance, which we can help you order
43
Has coverage been cancelled or non-renewed 5 years?
On any lines of coverage. If yes, please explain
44
Any bankruptcy, judgments, or liens in past 5 years?
45
Additional Description of Operations or Notes?
Please give a description of the services you provide or the work you do. If you have additional notes to share, you may use this space as well
46
Everything that I have stated in this application is true & correct to the best of my knowledge. I understand that information submitted will be verified during the rating process and that additional information may be requested prior to quote or coverage issuance.
47
Date
Date
Month
Day
Year
48
Applicant Signature
Clear
49
File Attachments (if applicable)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Current Policies, Declarations Pages, or Renewal Proposal. If you have property, auto, or equipment schedules, you may also upload them here.
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