Commercial Renewal Fast App

Commercial Renewal Fast App
Name of Business*
1st point of contact Email*
example@example.com
Website Address
1st Point of Contact name*

First NameLast Name
1st Point of Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
General LiabilityPropertyAutoWorkers CompErrors and OmissionsCyberDirectors and OfficersInland MarineCrimeUmbrellaBuilders RiskCargoBondExecutive Bonus Plans
YesNo
Describe any new products or services
Projected annual gross receipts*
Owner Payroll*
Employee Payroll*
Number of part-time employees*
Number of full-time employees*
Commercial General Liability
Commercial General Liability Coverage Information
Commercial General Liability Coverage Information
YesNo
Define new products or services offered
Annual reciepts for new products or services offered*
Annual payroll for new products or services offered*
YesNo
Insured sub costs*
Uninsured sub costs*
Commercial Property
Commercial Property Coverage Information
Commercial Property Coverage Information
YesNo
Confirm the number of locations you own or lease*
Location 1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business value if owned*
For Location 1 Address
Business personal property value*
For Location 1 Address
Location 2 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business value if owned*
For Location 2 Address
Business personal property value*
For Location 2 Address
Location 3 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business value if owned*
For Location 3 Address
Business personal property value*
For Location 3 Address
Location 4 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business value if owned*
For Location 4 Address
Business personal property value*
For Location 4 Address
Location 5 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business value if owned*
For Location 5 Address
Business personal property value*
For Location 5 Address
Commercial Auto
Commercial Auto Current Policy Breakdown
Commercial Auto Current Policy Breakdown
YesNo
YesNo
How many drivers do you have*
Driver list*

Cancelof
Driver 1*

First NameLast Name
Date of birth*

MonthDayYear
Date
License number*
Licensed state*
YesNo
Driver 2*

First NameLast Name
Date of birth*

MonthDayYear
Date
License number*
Licensed state*
YesNo
Driver 3*

First NameLast Name
Date of birth*

MonthDayYear
Date
License number*
Licensed state*
YesNo
Driver 4*

First NameLast Name
Date of birth*

MonthDayYear
Date
License number*
Licensed state*
YesNo
Driver 5*

First NameLast Name
Date of birth*

MonthDayYear
Date
License number*
Licensed state*
YesNo
Vehicle/Trailer Details
YesNo
YesNo
How many vehicles do you have
Vehicle List

Cancelof
Vehicle 1
Year*
Make*
Model*
VIN*
Trailer length (if applicable)
Garaging zip code of vehicle*
Value of vehicle*
Permanently attached equipment value (if any)
Vehicle 2
Year*
Make*
Model*
VIN*
Trailer length (if applicable)
Garaging zip code of vehicle*
Value of vehicle*
Permanently attached equipment value (if any)
Vehicle 3
Year*
Make*
Model*
VIN*
Trailer length (if applicable)
Garaging zip code of vehicle*
Value of vehicle*
Permanently attached equipment value (if any)
Vehicle 4
Year*
Make*
Model*
VIN*
Trailer length (if applicable)
Garaging zip code of vehicle*
Value of vehicle*
Permanently attached equipment value (if any)
Vehicle 5
Year*
Make*
Model*
VIN*
Trailer length (if applicable)
Garaging zip code of vehicle*
Value of vehicle*
Permanently attached equipment value (if any)
YesNo
How many days a year are you using non-owned trailers*
Workers Compensation
Workers Compensation Current Policy Breakdown
Workers Compensation Current Policy Breakdown
YesNo
Number of owners*
Owner 1 Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Title*
Duties*
*Note: If you choose to exclude owners from Worker's Comp benefits they must be at least 25% owner.
Owner percentage*
YesNo
Owner 2 Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Title*
Duties*
*Note: If you choose to exclude owners from Worker's Comp benefits they must be at least 25% owner.
Owner percentage*
YesNo
Owner 3 Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Title*
Duties*
*Note: If you choose to exclude owners from Worker's Comp benefits they must be at least 25% owner.
Owner percentage*
YesNo
Owner 4 Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Title*
Duties*
*Note: If you choose to exclude owners from Worker's Comp benefits they must be at least 25% owner.
Owner percentage*
YesNo
Owner 5 Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Title*
Duties*
*Note: If you choose to exclude owners from Worker's Comp benefits they must be at least 25% owner.
Owner percentage*
YesNo
Employee/Payroll Category

*Note: Employees Category Examples: Clerical, Driver, Technician, Retail, Electricians, HVAC, Plumbers, Artisan Contractor
Employee category 1*
Number of employees*
Payroll category total*
YesNo
Employee category 2*
Number of employees*
Payroll category total*
YesNo
Employee category 3*
Number of employees*
Payroll category total*
YesNo
Employee category 4*
Number of employees*
Payroll category total*
YesNo
Employee category 5*
Number of employees*
Payroll category total*
Errors and Omissions
Errors and Omissions Policy Breakdown
Errors and Omissions Policy Breakdown
YesNo
Cyber
Cyber Current Policy Breakdown
Cyber Current Policy Breakdown
YesNo
Directors and Offices
Directors and Offices Policy Breakdown
Directors and Offices Policy Breakdown
YesNo
Inland Marine
Inland Marine Policy Breakdown
Inland Marine Policy Breakdown
Inland Marine Schedule - Mobile Equipment
YesNo
YesNo
Equipment List*

Cancelof
Number of equipment you want to list*
Schedule any items at $500.00 or more
Item 1 description*
Serial number*
Make/Model*
Item value*
Item 2 description*
Serial number*
Make/Model*
Item value*
Item 3 description*
Serial number*
Make/Model*
Item value*
Item 4 description*
Serial number*
Make/Model*
Item value*
Item 5 description*
Serial number*
Make/Model*
Item value*
Total updated value of misc. tools/equipment ea. item under $500*
Example: hammers, drills, bits combined equal $2k
Crime
Crime Current Policy Breakdown
Crime Current Policy Breakdown
YesNo
Umbrella
Umbrella Current Policy Breakdown
Umbrella Current Policy Breakdown
YesNo
Builders Risk
Builders Risk Current Policy Breakdown
Builders Risk Current Policy Breakdown
Date Construction Started*

MonthDayYear
Date
Expected Completion Date*

MonthDayYear
Date
Cargo
Current Cargo Policy Breakdown
Current Cargo Policy Breakdown
YesNo
YesNo
Describe changes in cargo hauled*
Bond
Current Bond Policy Breakdown
Current Bond Policy Breakdown
YesNo
YesNo
Any loose ends
YesNo
Describe the "other" coverage increase you're seeking*
General LiabilityPropertyAutoWorkers CompErrors and OmissionsCyberDirectors and OfficersInland MarineCrimeUmbrellaGroup HealthBuilders RiskCargoBondExecutive Bonus PlansOtherN/A
Other coverage requested*
YesNo
YesNo
YesNo
YesNo
Great! Thank you for filling up the form and we will be in touch shortly!
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Commercial Renewal Fast App

Commercial General Liability

Commercial Property

Commercial Auto

Vehicle/Trailer Details

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Workers Compensation

Employee/Payroll Category

Errors and Omissions

Cyber

Directors and Offices

Inland Marine

Crime

Umbrella

Builders Risk

Cargo

Bond

Any loose ends