Business Application Form
General Business Information:
Business Name:
Owners Name
First Name
Second Name
Phone Number
Policy Holder Email Address
Mailing Address
Street Address
Suite / Apt Number
City
State
Zip Code
Primary Business Address
Street Address
Suite / Apt Number
City
State
Zip Code
Business Type (e.g. LLC, Sole Proprietorship, Partnership, Corporation, etc.
Federal Tax ID
State ID
Describe your business operations?
How long have you been in business?
Are you licensed in the state of domicilied?
Yes
No
Do you operate in other states besides home state?
Yes
No
Operations and Locations
Where is your business located? (home, building, owned, leased, etc.)
Policy Start Date:
-
Mes
-
Día
Año
Date
Most Popular Coverages
Business Owners Policy
General Liability
Commercial Property
Professional Liability (E&O)
Cyber Liability
Directors & Officers Liability
Employment Practices Liability
Bond
Crime
Commercial Flood
Umbrella
Coverage Limits You Require
100,000
300,000
500,000
1,000,000
2,000,000
5,000,000
10,000,000
Business Details
Estimated Total Gross Revenue for Next 12 Months:
Number of Employees (excluding business owners)
Full Time Employees:
Part Time Employees:
Estimated Wages at Primary Business Address for Next 12 Months:
Business Owners Only:
Full Time, Part Time, and Temporary Employees:
1099 Contractors:
Have you had any claims or lawsuits in the past five years?
Yes
No
If so, what were the outcomes?
Has this business had a lapse of coverage, been declined, canceled, or non-renewed in the last 3 years?
Yes
No
Percentage of job locations (e.g. residential, commercial, industrial=
Percentage of Projects by Type: (e.g. new construction, renovations, repairs)
Average Project Size (Cost):
Risk and Liability Exposure
Any work performed 3 stories or higher:
Yes
No
Do you perform work involving heavy machinery, excavation, or demolition:
Yes
No
Do you perform work involving Structural Changes or High-Rise Buildings:
Yes
No
Do you require bonds for certain projects?
Yes
No
Any worked performed in New York?
Yes
No
Building Information
Does the building contain an automatic sprinkler system?
Yes
No
Fire Protection Systems and Services Currently in Place:
Security Systems and Services Currently in Place:
Number of Floors in the Building:
Approximate Square Footage of Business Occupancy:
Approximate Total Square Footage of the Building:
Approximate Year the Building Was Completed:
Construction Type:
Frame
Joisted Masonry
Masonry Non-Combustible
Non-Combustible
Fire Resistive
Modified Fire Resistive
Total Value of Building(s) at This Location:
Total Value of Business Personal Property at This Location:
Updates of Property - Electrical (Year of Update)
Updates of Property - Plumbing (Year of Update)
Updates of Property - HVAC (Year of Update)
Updates of Property - Roofing (Year of Update)
Employee and Payroll Details
How many full-time and part-time employees do you have?
Do you hire subcontractors?
Yes
No
What is your total payroll, including subcontractors?
Do you have workers compensation coverage for your employees?
Yes
No
Property and Equipment
Do you own or lease equipment? (Specify types: vehicles, tools, heavy machinery)
How is your equipment stored when not in use?
Do you transport equipment and materials?
Yes
No
If so, what are the distances involved?
Commercial Auto Exposure
Do you have a vehicle owned or leased to the business?
Yes
No
If so, how many and what types?
Are vehicles used only for business purposes?
Yes
No
Profesional Liability
Do you offer design or engineering services as part of your contracting work?
Yes
No
Are there any professional licenses or certifications required for your work?
Yes
No
Coverage Needs
What types of insurance do you currently have? (e.g., general liability, workers'compensation, commercial auto)
Are you interested in coverage for tools and equipment, professional liability, orpollution liability?
Safety and Risk Managment
Do you have a formal safety program in place?
Yes
No
What training do employees receive to mitigate risk on job sites?
Do you have any ongoing or regular safety audits or inspections?
Yes
No
Future Plans
Are you planning to expand your business in the next few years?
Yes
No
Are there any specific risks or concerns you'd like addressed in your coverage?
Coverage Configuration
Liability Limits (Per occurrence limit / Aggregate limit):
$1,000,000
$2,000,000
Medical Payments Limit
Firma
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