SURVEYOR PACKAGE POLICY

  • SURVEYOR & ENGINEER PACKAGE POLICY

    Application 20240501

  • GENERAL INFORMATION

  • Business Type
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Proposed Effective Date
     / /

  • PACKAGE POLICY (GENERAL LIABILITY AND PROPERTY)

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  • Are You in the City Limits?
  • Do You Have a Central Station Alarm?
  • Construction Material of Building
  • Do You Use Watercraft in Your Business?
  • Is Your Equipment Ever Waterborne?
  • Have You Had Continuous Coverage for the Past 3 Years?
  • Have You Had Any Claims in the Last 3 Years?
  • Liability Limits Desired:
  • Check if you need coverage for:
  • Do You Do Oil/Gas Work?

  • WORKERS' COMPENSATION

    Estimated Payroll for the Upcoming 12 Months

    Please Note: Maximum Payroll to include is

    • $43,000 for Self-Employed/Sole Proprietors
    • $62,400 for Executive Officers
  • Rows
  • Rows
  • Do You Have Any Waivers of Subrogation?
  • Have You Had Continuous Workers' Comp Coverage for the Past 3 Years?
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  • Have You Had Any Claims in the Past 3 Years?
  • Liability Limits Desired:
  • Are the Owners Covered by Health Insurance?

  • COMMERCIAL AUTO INSURANCE

    Please note that if you use your own personal auto, you do NOT need to provide commercial auto insurance information.

  • Limits Desired:
  • Rows

  • * What the vehicle cost new is only required if you want full coverage (physical damage) on the auto. Even if you bought it used, estimate cost new.

    ** If you only want liability coverage, mark "N/A".

  • Rows
  • Have You Had Continuous Coverage for the Past 3 Years?
  • Have You Had Any Claims in the Past 3 Years?

  • ADDITIONAL COMMENTS

     

  • SUBMISSION INFO

    The applicant has read the foregoing and understands that completion of this Application does not bind the Underwriter or the Broker to provide coverage. It is agreed, however, that this Application is complete and correct to the best of applicant's knowledge and belief and that all particulars which may have a bearing upon acceptability as a Professional Liability insurance risk have been revealed. It is understood that this Application shall form the basis of the contract should the Underwriter approve coverage and should the applicant be satisfied with the Underwriters quotation.

  • Date Signed
     / /

  • IMPORTANT: Must select "Yes" for acknowledgment and sign above before submission.

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