Application for Insurance

Application for Insurance

Innovative BPS LLC: A Pinecrest Company
This dynamic application will guide you through providing the information needed to obtain insurance quotes. Depending on your industry and the line(s) of insurance you are interested in, the application may take between 5-15 minutes.

Click the "Save" button between sections to ensure your data is protected from browser or connection issues or if you need to finish another time.
Basic Business Info
Applicant Name*

First NameLast Name
Job Title *
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Business Name *
DBA
How is your business structured?*
Federal EIN*
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Which insurance line(s) are you interested in?*

Worker's Compensation
What is your industry? (Type below to search list.)*
NOTE: We currently only offer Auto / GL in the following States: AZ, CT, FL, IL, MD, NJ, NC, PA, OH, TX, VA, GA
Why are you shopping for insurance?*
When was your business established?*
EX: 03/2020
Amazon Program Info
Amazon Program*

AMZL(Amazon Logistics DSP)AMXL (Amazon Extra Large DSP)RSR (Rural/Super Rural DSP)AFP (Freight Partner)Walkers
Launch Date with Amazon*

MonthDayYear
Date
Amazon Station Code(s)
If multiple, separate codes with commas.
Amazon Company Short Code
Your unique, 4-letter Amazon short code.
TIP: Click "Save" at the bottom of each page to save your progress as you go.

Please describe your business operations.*
What do you do and how?
Do you have operating locations that are different from your mailing address?*

YesNo
Please add the addresses for your location(s) and a description of the opeartions at each location.*

What's the estimated average number of miles a vehicle drives per day?*
What is the maximum weight (in lbs.) of any item being handled or delivered?

	% of Driving (Approximate)
Rural
Suburban
Metro/Urban

Please provide the following information for all owners/officers.*

	First Name	Last Name	Total Annual Payroll	% Ownership	Want WC Coverage?	Job Duties
Primary Owner/ Officer
Owner / Officer 2
Owner / Officer 3
Owner / Officer 4
Owner / Officer 5

Please describe owner job duties listed as "Other" above.*
Please describe company ownership's prior business / management experience. (If you are a DSP/AFP, and have additional prior related experience, please describe that as well.)*

Current & Prior Coverage
Were your policies ever canceled by another broker or insurance company?*

YesNo
Why were your policies canceled?*
What is the expiration or termination date of your current Worker's Comp. policy? (Use most recent policy if you do not have current coverage.)*

MonthDayYear
Date
What is the current annual premium on your Worker's Comp. policy? (NOTE: Optional, but some of the lowest-cost carriers will not shop a policy without this information to determine whether they will be competitive. This will NOT cause your quotes to come back higher.)
Does your DSP use a return-to-work / light-duty program to reduce time-off losses?
What is the expiration or termination date of your current Auto policy? (Use most recent policy if you do not have current Auto coverage.)*

MonthDayYear
Date
What is the current premium on your Auto liability policy? (Optional but strongly recommended to provide: auto carriers are increasingly picky and many underwriters will not engage without this information. Providing the expiring premium helps us obtain as many quotes as possible.)
Loss Runs / Claims History
Carriers must review loss runs (claims history) for all lines you wish to shop. Auto carriers require 3 years of loss runs. Worker's Compensation require 4 years and a Mod Worksheet, if you have one. (If your business is not that old, provide all available.) Do you have any loss runs or a worksheet available to upload right now?*

Yes, I am uploading ALL applicable loss runs and/or a mod worksheet.Yes, I am uploading some loss runs and/or a mod worksheet.No, I am not uploading any loss runs or a mod worksheet at this time.
To shop for Auto coverage, we will need the following:
- Vehicle list in excel format
- Driver list in excel format
- 6 months of consecutive scorecards
- 3 years of loss runs
- RGU map showing radius of operating area (screenshots acceptable)
Upload your available loss runs and/or mod worksheet here. (NOTE: Please obtain and upload spreadsheets [XLS/XLSX] if available.)*

Cancelof
For loss runs that have not been uploaded, how would you provide them to us?

I will obtain them myself and email to pc-loss-runs@pinecrestconsulting.com.N/A - I do not have any prior losses to report.
For your convenience, our system can generate and send a letter on your behalf to the carrier(s) you name below in order to obtain your loss runs. By selecting this option, you authorize and appoint Innovative BPS LLC dba Pinecrest Innovative Insurance Agency to act on your behalf in sending this loss run request and to obtain insurance quotes for you. This form does not bind any coverage or create any obligations. You can revoke this authorization at any time by emailing pc-agency@innovativebps.com. The following message will be sent:

Please send me my company's complete loss history showing all claims experience, open and closed, across all applicable lines. If available, please send the detail in a CSV or XLSX format in addition to any available PDF reports.

Thank you,

{applicantName}, {jobTitle}
{businessName}
EIN: {federalEin}

I authorize the National Council on Compensation Insurance (NCCI) or my state's Worker's Compensation agency to release my Risk History Report and any experience rating worksheets directly to Innovative BPS LLC [dba Pinecrest Innovative Insurance Agency] for purposes of providing insurance quotes. This authorization is valid for one year from the signature date. Innovative BPS LLC is acting on my company's behalf regarding workers compensation insurance and requires this information. I agree that NCCI or my state agency will have no liability releasing the information as requested.
Please sign below.

Powered by Jotform SignClear
Anything else you'd like to tell us about your business or insurance needs?
Notification Email (Hidden)
example@example.com
Should be Empty:

	# Owned	# Leased	# Rentals
Car / Pickup / SUV
Cargo / Sprinter Vans
Step Vans / CDV
Electric Delivery Vans / EDV
Box / Straight Trucks
Semi-Trucks
Other

	Avg. # Part-Time	Avg. # Full-Time	Total Annual Payroll $
Drivers - No Install or Assembly
Drivers - Some Install or Assembly
Dispatch & Clerical - No Loading or Driving
Dispatch & Clerical - Some Loading or Driving

	Job Type	Avg. # Part-Time	Avg. # Full-Time	Total Annual Payroll $
1
2
3
4
5

	Carrier Name	Insurance Line	Policy #	Start Date	End Date
1
2
3
4
5
6
7

Application for Insurance

Basic Business Info

Amazon Program Info

TIP: Click "Save" at the bottom of each page to save your progress as you go.

Current & Prior Coverage

Loss Runs / Claims History