Commercial Insurance Application

Business Name*
Business Entity Type:*

Sole ProprietorPartnershipLLCCorporationOther
DBA/Tradename
Contact Name*

First NameLast Name
Contact Title
President, Manager, etc..
Contact Name and Title*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Description of Operations *
Years in Business*
FEIN*
Years of management experience in this industry*
Contractor’s License # (if required in any state in which the applicant operates)
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Address
Year Built*
Your Building you operate out of
Building Square Footage*
Construction Type of Building

FrameMasonryNon CombustibleMasonry Non-CombustibleOther
Building Coverage Amount (Building Owner)
Tenants Improvements and Betterments Coverage Amount (Building Tenant/Owner)
Business Property (Contents) Coverage Amount
Location Deductible
General Liability Limit
Total Gross Annual Receipts (please split commercial vs residential)*
Percentage of Gross Annual Receipts from Work Subcontracted by the Applicant
Number of Active Owners (excluding clerical)*
Owner/Officer Names and % Owned*
Owner Date of Birth*

MonthDayYear
Date
Owner Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Full-time Employees*
Number of Part-time Employees*
Annual Payroll (Broken Down by Position Group)*
Total Replacement Cost Estimate of Tools and Equipment for Blanket Coverage (items under $2,000)
Total Replacement Cost Estimate for Tools and Equipment for Scheduled Coverage(a detailed list of items over $2,000 in value will be required)
Garage Keepers Coverage Needed

YesNo
Renewal Date (Approximate)*

MonthDayYear
Date
Current Carrier Name, Premium, and Policy #*
Loss History*
Additional Info/Comments/Needs
AUTO DETAILS
# of Drivers*
# of Vehicles*
DRIVER INFORMATION

Please submit a spreadsheet or word doc if more than 1.
First Name
Last Name
DOB

MonthDayYear
Date
Driver’s License Number
State of License
We will ask for a list of all scheduled drivers.
VEHICLE INFORMATION

Can also submit an excel or word file
VIN
Special mounted equipment?
VIN
Special mounted equipment?
VIN
Special mounted equipment?
VIN
Special mounted equipment?
VIN
Special mounted equipment?
VIN
Special mounted equipment?
Attach Current Policy and Loss Runs

Browse Files

Cancelof
Should be Empty:

AUTO DETAILS

DRIVER INFORMATION

We will ask for a list of all scheduled drivers.

VEHICLE INFORMATION