Commercial - EZ Rate, General Liability, Habitational & Inland Marine

How did you hear about us?*

Are you already working with a team member at Schultze Agency? If so, select one:

Name Of Business*

Name*

Owner's First NameOwner's Last Name

Business Physical Address (Note if home based use home address here)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Do we have permission to communicate via text with you at this number?*

YesNo

Owner's Date of Birth

Date

Business Entity:

When Was Business Established*

Date

Is this an established business with previous insurance?

YesNo

How many years of management experience in this industry does the applicant have?

Does the named insured have other commercial policies insured with Farmers?

YesNo

Are there other businesses not insured by Farmers that are owned by the same Named Insured and not shown on this application?

YesNo

What is the company category that you are trying to insure?

E-Z Rate Contractor ProgramGeneral LiabilityHabitationalInland Marine

General Aggregate $

Products & Completed Operations Aggregate $

Each Occurrence $

Damage to Premises Rented to You $

Medical Expense (any one person) $

Deductible $

Number of Owner(s):

Total Number of Employees Excluding Owner(s):

Total Employee Payroll Excluding Owner(s):

1. Gross receipts current year:

Gross receipts previous year:

2. Years in business:

Prior years experience in this type of work:

3. Operation is:

Artisan Contractor %

General Contractor %

Subcontractor %

TOTAL 100%

Indicate type of work performed:

Residential / New %

Residential / Remodeling %

Commercial %

Condos/Townhouses %

Industrial %

Roofing %

TOTAL 100%

4. Exact business description and type of work performed:

5. Description of largest job(s):

6. Description of largest job(s):

What states do you operate in?

7. Do you now or have you ever acted as a Homebuilder or Residential GeneralContractor performing new construction?

YesNo

8. Do you now or have you ever acted as a Homebuilder or Residential GeneralContractor performing new construction?

YesNo

If yes, how many?

9. Do you perform excavation work?

YesNo

If so, do you use “Dig Safe” or a similar method of contacting utilities prior todigging?

YesNo

10. If so, do you use “Dig Safe” or a similar method of contacting utilities prior to digging?10. Do you perform any of the following? Explain “Yes” answers to the following questions in the remarks section below:

a. Do you draw plans, designs or specifications?

YesNo

b. Any demolition work?

YesNo

c. Any discontinued operations?

YesNo

d. Any guarantee, warranties or hold harmless agreements?

YesNo

e. Any roofing work performed?

YesNo

f. Any operation(s) involve discharge fumes, acids, wastes?

YesNo

g. Any exposure to radioactive / nuclear materials?

YesNo

h. Any equipment loaned / rented leased to others?

YesNo

i. Any work performed above 3 stories other than interior remodeling

YesNo

j. Does applicant install, service or demonstrate products?

YesNo

k. Any workperformed in removal of EIFS, asbestos, lead, mold, PCB, radon?

YesNo

l. Any work performed on road/bridges/highways/overpass/traffic signals?

YesNo

m. Any structural work performed?

YesNo

n. Any explosive materials used?

YesNo

o. Any underground boring or directional drilling?

YesNo

p. Any blasting operations?

YesNo

q. Any work on railroad easements?

YesNo

r. Any mold remediation?

YesNo

s. Any controlled burns or burning of debris?

YesNo

t. Any caisson work performed?

YesNo

If YES to any of the above, please describe in Remarks section:

REMARKS

11. Additional Insured:

Additional Insured Address:

What is the Additional Insured’s interest?

12.During the past 3 years has any company ever cancelled, declined or refused toissue similar insurance to applicant?

If so, explain

13. PREVIOUS INSURER AND PRIOR LOSS INFORMATION.

Has the insured or applicant had 3 years of prior coverage?

YesNo

If yes, please complete the Prior Insurer information for the past 3 years below (Year, Insurance Company, Policy # and Premium).

Has the insured or applicant had any prior claims or losses in the last 3 years?

YesNo

If yes, please complete the Loss information below (Date of Loss, Loss $ Amount Paid, Loss $ Amount Reserved and Description).

14. Any Work subcontracted?

YesNo

If yes, PLEASE COMPLETE NEXT SECTION. If no, THE FORM IS COMPLETE.

ADDITIONAL INFORMATION TO BE COMPLETED ONLY IF APPLICANT USES ANY SUBCONTRACTORS

16. Exact operations of sub contractors used:

16. Exact operations of sub contractors used: %

b. Total annual subcontracted costs (labor and materials) $

(Include costs ofmaterials provided by you, a subcontractor, an owner, or a bank.)

18. Type of work:

General Contractor %

Artisan Contractor %

Construction Manage %

19. What percentage of your work is

a) Residential %

Commercial %

Industrial %

b) New Construction %

Structural Remodeling / Additions %

Non-Structural Remodeling %

20. List the trades of the subcontractors you use and give the percentage of work they perform

21. Do you collect certificates from all subcontractors?

YesNo

What limits are required $

PLEASE NOTE THAT UNDER THE ARTISAN PROGRAM ALL SUBCONTRACTORS MUST PROVIDE CERTIFICATES OF INSURANCE FOR EQUAL LIMITS

22.Do you require all subcontractors to name you as an additional insured?

YesNo

23. Do any of the subcontractors you use perform any of the following work?

a. Roofing of any kind?

YesNo

b. Mold / Asbestos removal?

YesNo

c. Exterior Painting?

YesNo

d. Drilling of any kind?

YesNo

e. Spray Painting?

YesNo

f. Welding?

YesNo

24. Have you ever been named in litigation regarding faulty construction defect?

YesNo

If yes, describe:

25. Are there any claims or legal actions pending against any of the entities namedin the application?

YesNo

If yes, describe:

Please upload current declarations page if available

Any additional notes you would like us to know?

General Aggregate $

Products & Completed Operations Aggregate $

Personal & Advertising Injury $

Each Occurrence $

Damage to Premises Rented to You $

Medical Expense (any one person) $

Deductible $

Additional Insured (include Name/Address

Interest of Additional Insured:

Describe all business operations conducted by applicant

Locations, age and construction of all premises owned, rented or controlled by applicant (attach schedule if necessary):

Interest of applicant in such premises:Type, Owner, General Lessee, Tenant

Part occupied by the applicant: Type : Entire,Portion, or None

Does applicant have a parking lot?

If Yes state area

If applicant charges for the use of the parking lot, indicate gross receipts from this operation

Indicate type of surface: Type Gravel, Black Top or Concrete

Is the lot lighted?

Does risk store L.P.G., flammable liquids, ammunition, or explosives on the premises?

If yes, type and quantity stored

Does the applicant subcontract work?

If yes, state type

Are Certificates of Insurance required from all subcontractors

Type a question

During the past three years has any company ever cancelled, declined or refused to issue similar insurance to the applicant?

Has the insured or applicant had 3 years of prior coverage?

If yes please complete prior insurance information for the past 3 years.

(Date of Loss, Loss $ Amount Paid, Loss $ Amount Reserved and Description)

Has the insured or applicant had any prior claims or losses in the last 3 years?

PRIOR CARRIER INFORMATION- Carrier Name

Term Year

Premium

Type of Loss

Date of Loss

Amount Paid

Reserves

Description

Fire Sprinkler System:

Is the sprinkler system regularly maintained

Has the applicant submitted a Fire Sprinkler Certificate to the agent showing the building to be fully sprinklered and regularly maintained?

Number of Stories

Does the building have standpipes on each floor?

Are there approved and posted evacuation plans?

Number of Buildings

Number of Units

Unit Owners Coverage

Do you want to exclude Unit Owners Floor/Wall/Ceiling Coverage?

Number of Part time employees

Number of Full-time employees

Total annual sales or loss of rents form location

ADDITIONAL QUESTIONS

Answer Yes or No

	Yes	No
Are there any vehicles leased to others?
Is there hazardous cargo or hauling of goods, materials, or commodities that require Department of Transportation signs or lettering?
Are there any hold harmless agreements required?
Is the insured a grain hauling contract carrier?
Does the prospect have any vehicles that require an operating radius beyond 500 miles?
Are there courtesy vehicles?
Are there Public Transportation Exposures – other than Courtesy vehicles?
Are there specialty uses or is there sponsoring of Special Events?
Are there any oversized, overweight or unstable loads?
Are vehicles used to remove debris for a fee?
Are any listed vehicles used for the public to enter and receive a service or conduct Business?
Are any vehicles used to haul industrial or hazardous recyclables such as batteries used oil, or do any listed vehicles or the load require a hazardous material placard, or are any vehicles ambulances, armored carriers, or garbage trucks?
Are any vehicles used for garbage, waste, or trash removal?
Are any listed vehicles used to transport passengers to and/or from home?
Are any listed vehicles used to provide sightseeing tours?
Are there high-valued goods, including merchandise subject to theft?
Are there any vehicles that have Permanently Mounted Special Equipment?
Are there any vehicles that have been customized, altered, or that have Special Equipment?

Description of business operations

Driver First Name

Driver Last Name

Driver DOB

Drivers License Number

State of License

Drivers License Number

State of License

Driver First Name

Driver Last Name

Driver DOB

Drivers License Number

Driver First Name

Driver Last Name

Driver DOB

State of License

Additional Vehicles not listed upload list here

Do you have General Liability? If so list Company and expiration date below.

Do you have Umbrella Insurance? If so list Company and expiration date below.

Do you haveEPLI? If so list Company and expiration date below.

Do you have Pollution Liability? If so list Company and expiration date below.

Do you have Business Life? If so list Company and expiration date below.

Do you have Personal Lines? If so list Company and expiration date below.

Any additional notes?

	Yes	No
Does the applicant hire contract employees or pay employees with a 1099?
If Yes, did the applicant start this practice prior to this year?
Does the applicant subcontract any work?
If Yes, are all subcontractors hired by the applicant required to provide a certificate of insurance?
Self-insured/Professional Employer Organization (PEO)/Captive?
Is the applicant’s WC coverage currently canceled or pending cancellation?
Has the applicant ever had its WC coverage canceled (for reasons other than non-payment) or non-renewed within the last 3 years, or had a lapse in coverage within the last 3 years?
Have there been any loss occurrences in the past 3 years?
Do you have Loss Runs that are no more than 120 days old?

Business Insurance Quote Form

E-Z Rate Contractors Program

General Liability Application

Habitational

Auto Coverage Section

Inland Marine Application

Manufacturing

Restaurant