Commercial Fast App

Commercial Fast App
Name of Business*
Website
Contact Person*

First NameLast Name
Email*
First Point of Contact
Contact Number*
First Point of Contact
How did you find us?*

ReferralGoogleSocial MediaOther
Referred By

First NameLast Name
Referral Source
Desired Effective Date*

MonthDayYear
Date
How Many Owners?*
1st Owner Name*

First NameLast Name
Owner Percentage*
2nd Owner Name*

First NameLast Name
Owner Percentage*
3rd Owner Name*

First NameLast Name
Owner Percentage*
List name of all Owners and percentage owners*
FEIN
SSN (If no FEIN)
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your physical address the same as your mailing address?*

YesNo
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Entity Type:*

AssociationCorporationIndividualLimited Liability Company (LLC)PartnershipTrustOther
Other Entity*
Description of Operations
Years of Experience (Owner)
Year Business Started
Current Insurance Company
Expiration Date

MonthDayYear
Date
Reason for Shopping Insurance
Projected Annual Gross Receipts
Projected Annual Payroll
Number of Full Time Employees
Number of Part Time Employees
Do you have any contract (insurance) requirements?

YesNo
Insurance Requirements Uploads

Cancelof
Any losses in the last 5 years?*

YesNo
Date, Description, and Estimated Loss
Coverage Requested
Select all that applies*

General LiabilityPropertyCommercial AutoWorkers CompensationUmbrellaBuilders RiskBondOtherBusiness Owners Package (BOP)
Other Coverage Details

End of Locations

Start of Auto
Commercial Auto
Driver Details
Do you have a Driver List file available for upload?*

YesNo
Driver List*

Cancelof
How many drivers do you have?*

Driver 1
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
License Number*
Licensed State*

Driver 2
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
License Number*
Licensed State*

Driver 3
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
License Number*
Licensed State*

Driver 4
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
License Number*
Licensed State*

Driver 5
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
License Number*
Licensed State*

Vehicle 1
Year
Make
Model
VIN Number*

Vehicle 2
Year
Make
Model
VIN Number*

Vehicle 3
Year
Make
Model
VIN Number*

Vehicle 4
Year
Make
Model
VIN Number*

Vehicle 5
Year
Make
Model
VIN Number*

End of Vehicle
Commercial Auto Additional Notes

Start of Workers Compensation
Workers Compensation
Does your business have a documented Safety Program?*

YesNo
Safety Program Documents*

Cancelof
Employee/Payroll Details

*Note: Employee Category Examples: Clerical, Driver, Technician, Retail, Electricians, HVAC, Plumbers, Artisan Contractor
List the Employee Category, Number of Employees, and Payroll Category Total*
One category per line
Workers Compensation Additional Notes

Start of Umbrella
Umbrella
Limits of Liability*
Deductible*
Umbrella Additional Notes

Start of Builders Risk
Owner Name*

First NameLast Name
Builder Name*

First NameLast Name
Are you the owner or contractor?*

OwnerContractor
Property Location Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many buildings are at this location?*
Please prove the list of buildings at this location
Distance to Fire Hydrant*
Distance to Fire Station*
Remodeled or New Construction?*

RemodeledNew Construction
Pre-Construction Value*
Year of Original Construction*
Description of Renovations*
Has Construction Begun?*

YesNo
Construction Start Date*

MonthDayYear
Date
Expected Completion Date*

MonthDayYear
Date
Flood Needed?*

YesNo
Mortgage Company
Buidrers Risk Documents Submit

Cancelof
Builders Risk Additional Notes

End of Form
By clicking "Submit", I First Name* Last Name* hereby appoint Independence Insurance Center (IIC) as my Broker of Record for all lines of business and acknowledge that: (i) The above information provided to IIC Independence Insurance Center is true and correct, and (ii) if untruthful or inaccurate, may result in an increase in premium, or rejection, cancellation, or rescission of my policy by the insurance company. I further understand that this document does not infer or bind coverage of any kind. My agent has fully explained and provided me with ample opportunity to ask any questions concerning all coverages, limits, and insurance companies available.
Should be Empty:

Commercial Fast App

Coverage Requested

Commercial General Liability

Commercial Property

Commercial Auto

Workers Compensation

Errors and Omissions

Umbrella

Group Health