Barnum-Brown Insurance, Inc._02-0454-00

Commercial Quote Information Sheet

Barnum-Brown Insurance, Inc.
General Information:
Does customer have current coverage?
Effective Dates:
Current Carrier:
Current Premium: $
Customer Name:
Contact Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is billing address same as above?
County:
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Cell Number:
Please enter a valid phone number.
Email Address:
example@example.com
FEIN/SS#:
Year Business Started:
Direct Employees of Contractor:
Business Type:

Sole ProprietorCorporationPartnershipSubchapter “S”
Managers/Owners Years Experience:
Insurance needed:

GLAutoEquipmentPropertyUmbrellaWork Comp
Any known claims history on any lines of coverage?
Upload current insurance declarations pages:

Cancelof
Description of Operations:
Please provide a description of operations below:
Workers' Compensation:
Limits Required (*these limits are in hundreds of thousands):

$100/500/100 (State Required Minimum)$500/500/500$1Mil/1Mil/1Mil
Number of Employees?
Are Sub Contractors Used?
Are Certificates Required for Sub Contractors?
Job Descriptions (to add another job, click the "Add Job Description" button below):
Payroll for Sub Contractors (if any):
Excluded Officers/Owners (to add the next officer/owner, click the "Add Another" button below):
5 Year Loss History (loss runs are best):
NCCI Experience Mod:
General Liability:
Limits:

300,000/600,000500,000/1,000,0001,000,000/2,000,000
Total Direct Payroll: $
Gross Receipts: $
For Contractors:
Are Sub Contractors Used?
Total Sub-Contracted Work Cost: $
Insured Sub Cost $
Uninsured Sub Cost: $
% Commercial Work:
% Residential Work:
% Work Sub-Contracted:
Type of Work Sub-Contracted:
Are Certificates Required on Subs?
*Complete description of operations from above, will be fine to use as rating class for General Liability.
Notes:
Equipment:
Equipment (to add another piece of equipment, click the "Add Equipment" button below):
Storage Practice:
Employee Tools Value (if any):
Owned and Borrowed Limit:
Unscheduled Tools (Total Value):
Rental Expense Reimbursement:

YesNo
Rented/Leased Contractors Tools & Equipment Value: $
Notes:
Auto:
Limits of Liability:
Filings:

YesNo
If yes, what type:

ICC/GAForm E
Physical Damage Deductible:
Comprehensive:
Collision:
Fire/Theft/Specified Perils:
MedPay:

YesNo
Rental:

YesNo
If a long haul trucking account, request the last 4 quarters IFTA reports.
Vehicle Schedule (to add another vehicle, click the "Add Vehicle" button below):
Driver Information (to add another driver, click the "Add Driver" button below):
Property:
Location Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County:
Select One:

Owner OccupantTenantLessors Risk
(If rental) Type of Operation:
Building Value: $
Personal Property Limit: $
Construction Type:

FrameMasonryOther
Roof Type:
Year Built:
Total Area:
Number of Stories:
Basement:

YesNo
Sprinklers:

YesNo
Alarm Type:

LocalMonitored
If building is over 20 years old, Year of Last updates for Heat, Plumbing, Wiring, and Roof:
Loss Payee:
Umbrella:
Would you like Umbrella Insurance?

YesNo
Amount: $
Notes:
Please verify that you are human*
Should be Empty:

Commercial Quote Information Sheet