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

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.Format: (000) 000-0000.

Fax Number:

Please enter a valid phone number.Format: (000) 000-0000.

Cell Number:

Please enter a valid phone number.Format: (000) 000-0000.

Email Address:

example@example.com

FEIN/SS#:

Year Business Started:

Direct Employees of Contractor:

Business Type:

Managers/Owners Years Experience:

Insurance needed:

Any known claims history on any lines of coverage?

Upload current insurance declarations pages:

Description of Operations:

Please provide a description of operations below:

Workers' Compensation:

Limits Required (*these limits are in hundreds of thousands):

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:

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:

Rented/Leased Contractors Tools & Equipment Value: $

Notes:

Auto:

Limits of Liability:

Filings:

If yes, what type:

Physical Damage Deductible:

Comprehensive:

Collision:

Fire/Theft/Specified Perils:

MedPay:

Rental:

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:

(If rental) Type of Operation:

Building Value: $

Personal Property Limit: $

Construction Type:

Other

Roof Type:

Year Built:

Total Area:

Number of Stories:

Basement:

Sprinklers:

Alarm Type:

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?

Amount: $

Notes:

Please verify that you are human

Commercial Quote Information Sheet