COMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION SECTION
please be as detailed as possible and answer all questions
PLEAES MARK WHAT TYPE OF INSURANCE YOU NEED QUOTES FOR
GENERAL LIABILITY ONLY
GENERAL LIABILITY + PROPERTY (BUSINESS OWNERS POLICY)
GENERAL LIABILITY + WORKERS COMP
BUSINESS OWNERS POLICY + WORKERS COMP
WORKERS COMP ONLY
TODAYS DATE (MM/DD/YYYY)
/
Month
/
Day
Year
Date
REQUESTED EFFECTIVE DATE
/
Month
/
Day
Year
Date
REQUESTED EXPIRATION DATE
/
Month
/
Day
Year
Date
APPLICANT INFORMATION
DESCRIPTION OF OPERATIONS
NAMED INSURED
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
FEIN OR SS#
BUSINESS PHONE #
WEBSITE ADDRESS
NO. OF MEMBERS AND MANAGERS
TYPE OF ENTITY
INDIVIDUAL
PARTNERSHIP
JOINT VENTURE
TRUST
CORPORATION
LLC
NOT FOR PROFIT ORG
SUBCHAPTER "S" CORPORATION
Other
ARE YOU A GENERAL CONTRACTOR?
Please Select
NO
YES
CONTACT INFORMATION
PRIMARY CONTACT
First Name
Last Name
PRIMARY CONTACT PHONE NUMBER
Please enter a valid phone number.
PRIMARY E-MAIL ADDRESS
example@example.com
SECONDARY CONTACT (IF THERE IS ONE)
First Name
Last Name
SECONDARY CONTACT PHONE NUMBER
SECONDARY E-MAIL ADDRESS
example@example.com
HOW LONG HAVE YOU BEEN IN BUSINESS
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LOCATIONS
HOW MANY LOCATIONS DO YOU HAVE
IF LEASE OR OWN COMMERCIAL SPACE
LOCATION ADDRESS (#1)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
# FULL TIME EMPLOYEES
# PART TIME EMPLOYEES
Total annual payroll
ANNUAL REVENUES
OCCUPIED SQUARE FEET
TOTAL BUILDING SQUARE FOOTAGE
ANY AREA SUB-LEASED TO OTHERS AT LOCATION #1?
Please Select
NO
YES
LOCATION ADDRESS (#2)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
# FULL TIME EMPLOYEES AT LOCATION #2
# PART TIME EMPLOYEES AT LOCATION # 2
Total annual payroll at location #2
ANNUAL REVENUES AT LOCATION #2
SQ FT OF LOCATION #2
TOTAL BUILDING SQUARE FOOTAGE OF LOCATION #2
DESCRIPTION OF OPERATIONS AT LOCATION #2
ANY AREA SUB LEASED TO OTHERS IN LOCATION #2?
Please Select
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ANNUAL REVENUES AT LOCATION #3
# FULL TIME EMPLOYEES AT LOCATION #3
# PART TIME EMPLOYEES AT LOCATION #3
Total annual payroll at location #3
SQ FOOTAGE OF LOCATION #3
TOTAL BUILDING SQUARE FOOTAGE OF LOCATION #3
ANY AREA LEASED TO OTHERS AT LOCATION #3?
Please Select
NO
YES
LOCATION #4
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
# FULL TIME EMPLOYEES AT LOCATION #4
# PART TIME EMPLOYEES AT LOCATION #4
Total annual payroll at location #4
ANNUAL REVENUES AT LOCATION #4
SQUARE FOOTAGE OF LOCATION #4
TOTAL BUILDING SQUARE FOOTAGE AT LOCATION #4
DESCRIPTION OF OPERATIONS AT LOCATION #4
ANY AREA LEASED TO OTHERS AT LOCATION #4
Please Select
NO
YES
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YEAR BUSINESS STARTED
DESCRIPTION OF PRIMARY OPERATIONS
APARTMENTS
CONDOMINIUMS
CONTRACTOR
INSTITUTIONAL
MANUFACTURING
OFFICE
RESTAURANT
RETAIL
SERVICE
WHOLESALE
# of additional interests
1
2
ADDITIONAL INTERESTS
ADDITIONAL INSURED
LIENHOLDER
INTEREST
LOSS PAYEE
CO-OWNER
EMPLOYEE AS LESSOR LEASEBACK OWNER LENDER'S LOSS PAYABLE
OWNER
REGISTRANT
MORTGAGEE
NAME OF ADDITIONAL INTEREST
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
REFERENCE / LOAN #
REASON FOR INTEREST
E-MAIL ADDRESS OF INTEREST
example@example.com
ADDITIONAL INTERESTS #2
ADDITIONAL INSURED
LIENHOLDER
INTEREST
LOSS PAYEE
CO-OWNER
EMPLOYEE AS LESSOR LEASEBACK OWNER LENDER'S LOSS PAYABLE
OWNER
REGISTRANT
MORTGAGEE
NAME OF ADDITIONAL INTEREST #2
INTEREST ADDRESS #2
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2ND REFERENCE / LOAN #
REASON FOR 2ND INTEREST
E-MAIL ADDRESS OF 2ND INTEREST
example@example.com
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GENERAL INFORMATION
IF YOUR ANSWER IS "NO" FOR ALL QUESTIONS BELOW, PLEASE SELECT FROM DROPDOWN
Please Select
NO
IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY?
Please Select
NO
YES
DOES THE APPLICANT HAVE ANY SUBSIDIARIES?
Please Select
NO
YES
IS A FORMAL SAFETY PROGRAM IN OPERATION?
Please Select
NO
YES
ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?
Please Select
NO
YES
ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OROPERATIONS?
Please Select
NO
YES
ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?
Please Select
NO
YES
DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD,BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY?
Please Select
NO
YES
ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS?
Please Select
NO
YES
HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS?
Please Select
NO
YES
HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?
Please Select
NO
YES
HAS BUSINESS BEEN PLACED IN A TRUST?
Please Select
NO
YES
ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR US PRODUCTS SOLD / DISTRIBUTED IN FOREIGN COUNTRIES?
Please Select
NO
YES
DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED?
Please Select
NO
YES
DOES APPLICANT OWN / LEASE / OPERATE ANY DRONES?
Please Select
N
Y
DOES APPLICANT HIRE OTHERS TO OPERATE DRONES?
Please Select
NO
YES
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PRIOR INSURANCE HISTORY
PAST 12 MONTHS INSURANCE CARRIER
POLICY NUMBER
EFFECTIVE DATE
-
Month
-
Day
Year
Date
EXPIRATION DATE
-
Month
-
Day
Year
Date
PRIOR YEAR #1 INSURANCE CARRIER
GENERAL LIABILITY
POLICY NUMBER
EFFECTIVE DATE
/
Month
/
Day
Year
Date
EXPIRATION DATE
/
Month
/
Day
Year
Date
PRIOR YEAR #2 INSURANCE CARRIER
GENERAL LIABILITY
POLICY NUMBER
EFFECTIVE DATE
/
Month
/
Day
Year
Date
EXPIRATION DATE
/
Month
/
Day
Year
Date
PRIOR YEAR #3 INSURANCE CARRIER
GENERAL LIABILITY
POLICY NUMBER
EFFECTIVE DATE
/
Month
/
Day
Year
Date
EXPIRATION DATE
/
Month
/
Day
Year
Date
UPLOAD CURRENT INSURANCE DECLARATIONS / POLICY
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LOSS HISTORY
Check if none
IF YOU HAVE HAD ANY CLAIMS, HOW MANY IN THE LAST 5 YEARS?
UPLOAD '3 YEAR LOSS RUNS'
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REGARDLESS IF YOU HAVE HAD A CLAIM OR NOT
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IF YOUR ANSWER IS "NO" FOR ALL QUESTIONS BELOW, PLEASE SELECT FROM DROPDOWN
Please Select
NO
DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS?
Please Select
NO
YES
DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL?
Please Select
NO
YES
DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING?
Please Select
NO
YES
DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS?
Please Select
NO
YES
ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE?
Please Select
NO
YES
DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS?
Please Select
NO
YES
$ PAID TO SUB-CONTRACTORS ON ANNUAL BASIS
DESCRIBE THE WORK TO BE CONTRACTED
% OF WORK SUBCONTRACTED ON ANNUAL BASIS
# FULL- TIME STAFF
# PART- TIME STAFF
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IF YOUR ANSWER IS "NO" FOR ALL QUESTIONS BELOW, PLEASE SELECT FROM DROPDOWN
Please Select
NO
ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED?
Please Select
NO
YES
ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS
Please Select
NO
YES
DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, ORTRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)
Please Select
NO
YES
ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS?
Please Select
NO
YES
DO YOU RENT OR LOAN EQUIPMENT TO OTHERS
Please Select
NO
YES
ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED?
Please Select
NO
YES
ANY PARKING FACILITIES OWNED/RENTED?
Please Select
NO
YES
IS A FEE CHARGED FOR PARKING?
Please Select
NO
YES
RECREATION FACILITIES PROVIDED?
Please Select
NO
YES
ARE THERE ANY LODGING OPERATIONS INCLUDING APARTMENTS?
Please Select
NO
YES
IS THERE A SWIMMING POOL ON PREMISES?
Please Select
NO
YES
ARE SOCIAL EVENTS SPONSORED?
Please Select
NO
YES
ARE ATHLETIC TEAMS SPONSORED?
Please Select
NO
YES
ANY STRUCTURAL ALTERATIONS CONTEMPLATED?
Please Select
NO
YES
ANY DEMOLITION EXPOSURE CONTEMPLATED?
Please Select
NO
YES
AS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES?
Please Select
NO
YES
DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
Please Select
NO
YES
S THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES?
Please Select
NO
YES
RE DAY CARE FACILITIES OPERATED OR CONTROLLED?
Please Select
NO
YES
HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS?
Please Select
NO
YES
S THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT?
Please Select
NO
YES
DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES
Please Select
NO
YES
DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS?
Please Select
NO
YES
FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS?
Please Select
NO
YES
RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED?
Please Select
NO
YES
GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS?
Please Select
NO
YES
PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY?
Please Select
NO
YES
PRODUCTS RECALLED, DISCONTINUED, CHANGED?
Please Select
NO
YES
PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER APPLICANT LABEL
Please Select
NO
YES
PRODUCTS UNDER LABEL OF OTHERS?
Please Select
NO
YES
VENDORS COVERAGE REQUIRED?
Please Select
NO
YES
DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS?
Please Select
NO
YES
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PROPERTY SECTION
DESCRIPTION OF PROPERTY TO COVER
BUILDING CONSTRUCTION TYPE
Please Select
WOOD FRAME
MASONRY
MASONRY NON-COMBUSTIBLE
NON-COMBUSTIBLE
LIGHT STEEL
# OF STORIES
# OF BASEMENTS
YEAR BUILT
TOTAL SQUARE FOOTAGE
ROOF TYPE
Please Select
OPEN GABLE
BOX GABLE
DORMER
M SHAPED
HIP
JERKINHED
DUTCH GABLE
COMBINATION
CROSS HIPPED
INTERSECTING/OVERLAID HIP
HIP AND VALLEY
HEXAGONAL
GAMBREL
MANSARD
SALTBOX
PYRAMID HIP
SHED
FLAT
BUTTERFLY
BUILDING IMPROVEMENTS
Rows
UPDATED
YEAR UPDATED/REPLACED
ELECTRICAL
PLUMBING
ROOFING
HEATING
IS THE BUILDING 100% SPRINKLERED?
Please Select
NO
YES
DO YOU HAVE A BURGLAR ALARM
Please Select
NO
YES, LOCAL ONLY
YES, CENTRALLY MONITORED
BURGLAR ALARM INSTALLED AND SERVICED BY
DO YOU HAVE A FIRE ALARM
NO
CENTRAL STATION/MONITORED
LOCAL FIRE ALARM
FIRE ALARM MANUFACTURER
PROPERTY (BUILDING) COVERAGE SECTION
BUILDING COVERAGE LIMIT
DEDUCTIBLE
BUSINESS PERSONAL PROPERTY (inventory, furniture, tenant improvements, etc.)
SELECT IF YOU WANT TO COVER BUSINESS PERSONAL PROPERTY
Please Select
BUSINESS PERSONAL PROPERTY
HOW MUCH COVERAGE DO YOU NEED FOR BUSINESS PERSONAL PROPERTY?
BUSINESS PERSONAL PROPERTY DEDUCTIBLE
IF YOU HAVE A 2ND LOCATION, PLEASE FILL OUT THIS PROPERTY SECTION
DESCRIPTION OF PROPERTY TO COVER AT LOCATION #2
BUILDING CONSTRUCTION TYPE LOCATION #2
Please Select
WOOD FRAME
MASONRY
MASONRY NON-COMBUSTIBLE
NON-COMBUSTIBLE
LIGHT STEEL
# OF STORIES AT LOCATION #2
# OF BASEMENTS AT LOCATION #2
YEAR BUILT LOCATION #2
TOTAL SQUARE FOOTAGE OF LOCATION #2
ROOF TYPE LOCATION #2
Please Select
OPEN GABLE
BOX GABLE
DORMER
M SHAPED
HIP
JERKINHED
DUTCH GABLE
COMBINATION
CROSS HIPPED
INTERSECTING/OVERLAID HIP
HIP AND VALLEY
HEXAGONAL
GAMBREL
MANSARD
SALTBOX
PYRAMID HIP
SHED
FLAT
BUTTERFLY
BUILDING IMPROVEMENTS LOCATION #2
Rows
UPDATED
YEAR UPDATED/REPLACED
ELECTRICAL
PLUMBING
ROOFING
HEATING
IS THE BUILDING 100% SPRINKLERED? (LOCATION #2)
Please Select
NO
YES
DO YOU HAVE A BURGLAR ALARM (LOCATION #2)
Please Select
NO
YES, LOCAL ONLY
YES, CENTRALLY MONITORED
BURGLAR ALARM INSTALLED AND SERVICED BY (LOCATION #2)
DO YOU HAVE A FIRE ALARM At LOCATION #2?
NO
CENTRAL STATION/MONITORED
LOCAL FIRE ALARM
FIRE ALARM MANUFACTURER AT LOCATION #2
BUILDING COVERAGE LIMIT LOCATION #2
DEDUCTIBLE LOCATION #2
BUSINESS PERSONAL PROPERTY (inventory, furniture, tenant improvements, etc.)
SELECT IF YOU WANT TO COVER BUSINESS PERSONAL PROPERTY AT LOCATION #2
Please Select
BUSINESS PERSONAL PROPERTY
HOW MUCH COVERAGE DO YOU NEED FOR BUSINESS PERSONAL PROPERTY AT LOCATION #2?
BUSINESS PERSONAL PROPERTY DEDUCTIBLE AT LOCATION #2
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WORKERS COMPENSATION
INSPECTION CONTACT NAME
INSPECTION CONTACT PHONE NUMBER
Please enter a valid phone number.
INSPECTION CONTACT EMAIL
example@example.com
PARTNER, OWNERS, OFFICERS, REALTIVES (must be employed by business operations)
Rows
NAME
DOB
TITLE
% OF OWNERSHIP
ANNUAL PAYROLL
INC / EXCL
1
CEO
PRESIDENT
VICE PRESIDENT
TREASURER
SECRETARY
PARTNER
OFFICER
MANAGER
INCLUDE
EXCLUDE
2
CEO
PRESIDENT
VICE PRESIDENT
TREASURER
SECRETARY
PARTNER
OFFICER
MANAGER
INCLUDE
EXCLUDE
3
CEO
PRESIDENT
VICE PRESIDENT
TREASURER
SECRETARY
PARTNER
OFFICER
MANAGER
INCLUDE
EXCLUDE
4
CEO
PRESIDENT
VICE PRESIDENT
TREASURER
SECRETARY
PARTNER
OFFICER
MANAGER
INCLUDE
EXCLUDE
5
CEO
PRESIDENT
VICE PRESIDENT
TREASURER
SECRETARY
PARTNER
OFFICER
MANAGER
INCLUDE
EXCLUDE
PRIOR WORKERS COMP INSURANCE HISTORY
Rows
INSURANCE COMPANY
POLICY #
ANY CLAIMS?
2023-2024
NO
YES
2022-2023
NO
YES
2021-2020
NO
YES
DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT / WATERCRAFT?
Please Select
N
Y
DO / HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, ORTRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)
Please Select
N
Y
ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?
Please Select
N
Y
ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?
Please Select
N
Y
IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?
Please Select
N
Y
ARE SUB-CONTRACTORS USED? (If "YES", give % of work subcontracted)
Please Select
N
Y
ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE? (If "YES", payroll for this work must be included in the State Rating Worksheet on Page 2)
Please Select
N
Y
IS A WRITTEN SAFETY PROGRAM IN OPERATION?
Please Select
N
Y
ANY GROUP TRANSPORTATION PROVIDED?
Please Select
N
Y
ANY SEASONAL EMPLOYEES?
Please Select
N
Y
IS THERE ANY VOLUNTEER OR DONATED LABOR?
Please Select
N
Y
Type a questionDO EMPLOYEES TRAVEL OUT OF STATE?
Please Select
N
Y
ARE ATHLETIC TEAMS SPONSORED?
Please Select
N
Y
ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?
Please Select
N
Y
ANY OTHER INSURANCE WITH THIS INSURER?
Please Select
N
Y
ANY PRIOR COVERAGE DECLINED / CANCELLED / NON-RENEWED IN THE LAST THREE (3) YEARS?
Please Select
N
Y
ARE EMPLOYEE HEALTH PLANS PROVIDED?
Please Select
N
Y
DO ANY EMPLOYEES PERFORM WORK FOR OTHER BUSINESSES OR SUBSIDIARIES?
Please Select
N
Y
DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
Please Select
N
Y
DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME?
Please Select
N
Y
If "YES", # of Employees:
ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST FIVE (5) YEARS?
Please Select
N
Y
ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR OWNED ENTERPRISES?
Please Select
N
Y
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