Business Owners Insurance Application
Requested effective Date
/
Month
/
Day
Year
Date
Business Name
Type of entity
Please Select
Sole Proprietorship
LLC
S-Corp
C-Corp
Partnership
Joint Venture
Non-profit
Contact name
First Name
Last Name
Owners name
Owners home address
Owners date of birth
Contact email
example@example.com
Contact phone number
Format: (000) 000-0000.
Website
Tax ID#
Type of Business
Mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Detailed Description of operations
Year this business started under the current ownership
Estimated annual gross sales
Years of total overall experience the owner has in this business type
Losses past 3 years
Yes
No
Upload your '3 year loss runs'
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Location address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
# of full-time employees
# of part-time employees
Estimated Total Annual Payroll
Current insurance company
Current insurance company policy number
Current insurance company expiration date
-
Month
-
Day
Year
Date
Upload current workers compensation policy
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If you need business property coverage, please fill out this section
How much business personal property coverage do you need?
How much did you spend on tenant improvements?
Year built
# of stories
Any residential units in the building?
No
Yes
Building construction
Wood Frame
Joisted Masonry
Steel
Light non-combustible
Total square footage
Do you own the building?
No
Yes
Year roof was last updated/replaced
Year electrical was updated/replaced
Year plumbing was updated/replaced
Year water heater was updated/replaced
Is the building 100% sprinklered?
No
Yes
Do you have a monitored burglar alarm?
No
Yes
Do you have a monitored fire alarm?
No
Yes
Anything else to add?
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