LifeStore Insurance_Commercial Lines - New Submission Quote Form

Named Insured (Include entity type & any dba):

Individual Business Owner(s) Name(s):

Contact Name:

First NameLast Name

Contact Phone Number:

Please enter a valid phone number.

Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Location Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email:

example@example.com

Web Site:

Date Business Started:

FEIN:

Type of Business:

Number of Employees (Full Time/Part Time):

Current Carrier/Policy Type/Exp Date/Prem:

Date Submitted to Marketing:

Quote Need by Date:

PROPERTY INFORMATION (* COMPLETE A SEPARATE FORM FOR EACH BUILDING):

LIABILITY INFORMATION

GL Limit:

Classifications:

Rating Basis (Payroll, Sales, Area):

Employee Benefits:

Hired & Non-Owned Auto:

AUTOMOBILE INFORMATION

Liability Limits (Liability, UM/UIM, MP):

Garaging Location Address:

Use of Vehicles:

Radius of Operation:

Hired Physical Damage Limit:

Do Owners have Pers. Auto Policy?

Is Broad Form Drive Other Car Coverage needed?

Vehicle Schedule:

Drivers:

WORKERS’ COMPENSATION INFORMATION

Limits:

FEIN:

Classification Code #1 (w/ payroll & # of employees):

Classification Code #2 (w/ payroll & # of employees):

Classification Code #3 (w/ payroll & # of employees):

Experience Modification Factor:

Number of FULL Time Employees:

Number of PART Time Employees:

Drug Testing Program:

Formal Safety Program:

Early Return to Work Program:

Health Insurance Offered to Employees:

Officers/Owners to be Incld or Excld:

Inland Marine/Scheduled Equipment

Description of Equipment:

	List Info Here (including Serial Number and Cost New)
Item #1
Item #2
Item #3
Item #4
Total Value for Small Tools:
Deductible:
Where are tools kept when not in use:

Commercial Umbrella

Limit:

Underlying Policy Information:

Additional/Suggested types if Insurance

EPLI/3rd Party:

Cyber/Data Breach:

Employment Benefits Liability/ERISA:

Directors & Officers Liability:

Earthquake:

Flood:

Other:

Narrative/Description:

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