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 Format: (000) 000-0000.
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*

Business Owners Package (BOP)BondGeneral LiabilityBuilders RiskPropertyUmbrellaWorkers CompensationOtherCommercial Auto
Other Coverage Details
- Commercial General Liability
- Square footage you occupy or own
- Liability Limits Requested
  
  1MM/2MM2MM/4MMOther
- Do you own or lease your property?
  
  OwnLeaseBoth
- Are you a contractor or general contractor?
  
  ContractorGeneral ContractorNeither
- Do you use subcontractors?
  
  YesNo
- Insured Sub Costs
- Uninsured Sub Costs
- Type of Work Subcontracted out to Insured Subcontractors
- Type of Work Subcontracted out to Uninsured Subcontractors
- % Residential Work
- % Commercial Work
- Any Waivers of Subrogation?
  
  YesNo
- Description of Work
  Performed as Contractor or General Contractor
- Do employees use their own vehicles in the business?
  
  YesNo
- Any Additional Insureds?
  
  YesNo
- Number of Additional Insured
- General Liability Additional Notes
- Commercial Property
- How many locations do you own or lease?*
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Is this a Condo?*
  
  YesNo
- Occupancy*
  
  OwnerTenantOther
- Monitored Alarm*
  
  LocalMonitoredNone
- Sprinklered*
  
  YesNo
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Is this a Condo?*
  
  YesNo
- Occupancy*
  
  OwnerTenantOther
- Monitored Alarm*
  
  LocalMonitoredNone
- Sprinklered*
  
  YesNo
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Is this a Condo?*
  
  YesNo
- Occupancy*
  
  OwnerTenantOther
- Monitored Alarm*
  
  LocalMonitoredNone
- Sprinklered*
  
  YesNo
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Is this a Condo?*
  
  YesNo
- Occupancy*
  
  OwnerTenantOther
- Monitored Alarm*
  
  LocalMonitoredNone
- Sprinklered*
  
  YesNo
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Is this a Condo?*
  
  YesNo
- Occupancy*
  
  OwnerTenantOther
- Monitored Alarm*
  
  LocalMonitoredNone
- Sprinklered*
  
  YesNo
- Commercial Property Additional Notes
- Commercial Auto
- Driver Details
- Do you have a Driver List file available for upload?*
  
  YesNo
- Driver List*
  
  Cancelof
- How many drivers do you have?*
- Name*
  
  First NameLast Name
- Date of Birth*
  
  MonthDayYear
  Date
- License Number*
- Licensed State*
- Name*
  
  First NameLast Name
- Date of Birth*
  
  MonthDayYear
  Date
- License Number*
- Licensed State*
- Name*
  
  First NameLast Name
- Date of Birth*
  
  MonthDayYear
  Date
- License Number*
- Licensed State*
- Name*
  
  First NameLast Name
- Date of Birth*
  
  MonthDayYear
  Date
- License Number*
- Licensed State*
- Name*
  
  First NameLast Name
- Date of Birth*
  
  MonthDayYear
  Date
- License Number*
- Licensed State*
- Vehicle Details
- Desired Liability Coverage*
- Uninsured Motorist*
- Personal Injury Protection*
- Collision & Comp Deductibles*
- Hired/Non-owned Liability*
  
  YesNo
- Rental Reimbursement*
  
  YesNo
- Roadside*
  
  YesNo
- Do any vehicles require "filings"?*
  
  YesNo
- Are all vehicles titled in the name of your business?*
  
  YesNo
- Title Variations*
  Identify the vehicles titled outside of the business and who is on the title for each
- Do you have a Vehicle List file available to upload?*
  
  YesNo
- Vehicle List*
  
  Cancelof
- How many vehicles do you have?*
- Year
- Make
- Model
- VIN Number*
- Year
- Make
- Model
- VIN Number*
- Year
- Make
- Model
- VIN Number*
- Year
- Make
- Model
- VIN Number*
- Year
- Make
- Model
- VIN Number*
- Commercial Auto Additional Notes
- 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
- Errors and Omissions
- Limits of Liability*
- Errors and Omissions Additional Notes
- Umbrella
- Limits of Liability*
- Deductible*
- Umbrella Additional Notes
- Group Health
- Company Desired Coverrages*
  
  Major MedicalDentalVisionLifeShort Term DisabilityLong Term DisabilityOther Ancillary Coverages
- Other Ancillary Coverages Types*
- 1. Download a copy of the Group Health Census Form.
  
  2. Fill it up with the necessary details
  
  3. Once completed, upload it below
- Group Health Census Form Upload*
  
  Cancelof
- Group Health Additional Notes
- 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
- 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