Business Name
*
Business Entity Type:
*
Sole Proprietor
Partnership
LLC
Corporation
Other
DBA/Tradename
Contact Name
*
First Name
Last Name
Contact Title
President, Manager, etc..
Contact Name and Title
*
Phone Number
*
-
Area Code
Phone 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
City
State / Province
Postal / Zip Code
Business Address
Year Built
*
Your Building you operate out of
Building Square Footage
*
Construction Type of Building
Frame
Masonry
Non Combustible
Masonry Non-Combustible
Other
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
*
-
Month
-
Day
Year
Date
Owner Home Address
*
Street Address
Street Address Line 2
City
State / 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
Yes
No
Renewal Date (Approximate)
*
/
Month
/
Day
Year
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
/
Month
/
Day
Year
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
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