Business Policy
Business Owners • General Liability • Professional Liability • Commercial General Liability • Worker's Compensation • Cyber Insurance
Business Legal Name
*
Owner 's Name
*
First Name
Last Name
Profession
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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When would you like coverage to Begin?
*
/
Month
/
Day
Year
Date
How is your business structured?
*
Please Select
Corporation
LLC
Joint Venture
Estate
Sole Proprietor
Professional Association
Trust
Other
For the next 12 months what is your expected Revenue
*
What Kind Of Coverage do you need ?
*
General Liability
Professional
Cyber
Do you have more than one location?
*
Yes
No
Approximately when did you start business?
*
-
Month
-
Day
Year
Date Picker Icon
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Aggregate Limit
*
Please Select
$250,000
$500,000
$750,000
$1,000,000
This is the total amount that will be paid for damages. claim expenses and supplemental payments during the policy
Each Claim Limit
*
Please Select
$250,000
$500,000
$750,000
$1,000,000
This is the amount that will be paid for all damages and medical expenses that arise of any one occurrence. Defense cost incurred in the defense of a lawsuit will not reduce the limit.
Deductible
*
Please Select
$1,000
$1,500
$2,500
$5,000
$7,500
$10,000
Waiver of Subrogation
*
Please Select
Include
Exclude
This waives the right of the insurer to legally pursue a negligent third party that causes a loss. It is sometimes required as part of contractual agreements
Contingent Bodily Injury and Property Damage
*
Please Select
Include
Exclude
Covers bodily and property damage claims out of your professional services.
Contingent Bodily Injury and Property Damage Coverage Limit
*
Please Select
$50,000
$100,000
$200,000
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Do you or your business supply, manufacture, or distribute any tangible products or goods?
Yes
No
Does your business perform any design, construction, Installation removal, or physical repair of any property or tangible goods?
Yes
No
Is your business operated out of your home?
Yes
No
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Terrorism Coverage
*
Please Select
Include
Exclude
Covers losses that arise out of a certified act of terrorism as defined by the Terrorism Risk Insurance act
Business Property and Equipment
*
Please Select
Include
$5,000
$10,000
$15,000
$20,000
$25,000
Exclude
Please select coverage limit Covers loss to business personal property such as computers, printers and furniture some carriers also include coverage for personal property away from premises
Approximately how many square feet does your business occupy at this location
*
Hired Auto and Non-Owned Auto
*
Please Select
Include
$300,000
$500,000
$1,000,000
$2,000,000
Exclude
Covers your business for bodily injury or property damage claims by someone outside your organization, which arise out of you or your employee driving a rented or non-owned (i.s. your employee's personal car)vehicle for business purposes
Waiver of Subrogation
*
Please Select
Include
Exclude
Waives the carriers right to legally a negligent third party that causes a loss. May be required by contracts or services you provide.
Primary and Non-Contributory
*
Please Select
Include
Exclude
As part of a contractual agreement, this coverage makes the insurance primary, meaning this policy it will pay before any other insurancethat is available and will not seek contribution
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Cyber Coverage Sections
OPTIONAL you can skip this page
Including your self, how many full time , Part time, and temporary employees does your business have (Do not include subcontractors)
An employee is someone who works for the business part-time, full-time or under contract, which can be oral or written. This does not include third-party contractors. For informational purposes please include all employees including the owner(s)
Do you conduct annual training for employees in respect to privacy matters?
Please Select
Yes
No
Privacy matters refers to failure to protect sensitive information, including subsequent actions by a regulator
What are the retroactive dates for your current Cyber and Media Liability policies?
If you do not know right now you can type I don't know.. Some carriers do require it
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Cyber Limits and Options
OPTIONAL
Aggregate Limit
Please Select
$250,000
$500,000
$1,000,000
Per Occurrence limit is same as aggregate.
Deductible
Please Select
$1,000
$5,000
$10,000
$15,000
$20,000
$25,000
Media Liability
Please Select
Include
Exclude
Covers to defend and resolve claims related to online content, such as copyright or trademark infringement, invasion of privacy, defamation, unintentional infliction of emotional distress, unfair practices and negligence in connection with your media activities.
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Holy Crap! You're Done. That's all the info we need to get started
If we have any other questions we'll reach out. This is just a basic questionnaire. Depending on the type of business we may have more questions but we will check multiple carriers to try and find the right fit
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