Commercial Insurance Application
General Information
Applicant Name
*
First Name
Last Name
Business Name
*
Legal Entity
*
Individual
LLC
Partnership
Nonprofit
Email
*
Contact Number
*
Format: (000) 000-0000.
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Describe your business operations
*
0/500
FEIN
Number of employees
*
Including owner
Start date of the business
*
-
Month
-
Day
Year
Gross Annual Revenue ($)
*
Insurance coverage requested
*
General Liability
Commercial Property
Commercial Auto
Professional Liability
Workers' compensation
FEIN
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PROPERTY DETAILS
Do you have current insurance?
Yes
No
Current Carrier
Building Information
Construction Type
Please Select
fire-resistive
non-combustible
ordinary
heavy timber
wood-framed
other
Year Built
Insured sq feet
Year Renovated
Rows
Renovated Year
Roof
Electrical
Plumbing
Heating
Building Security
Rows
Local
Central
None
Fire Alarm
Burglar Alarm
Building Property Value ($)
Business Property Value ($)
Equipment , Furniture, etc
Business Inventory Value ($)
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GENERAL LIABILITY
Are you requesting General Liability Coverage due to a contract?
*
Yes
No
Desired Amount of General Liability Coverage ($)
*
Please Select
1 Million / 2Million
2 Million / 2 Million
Annual Payroll for Subs ($)
*
Annual Payroll Owners ($)
*
Does you use Independent Contractors (ICs) or Sub Contractors?
*
Yes
No
Underwriting Questions
*
Rows
Yes
No
N/A
Do you request Certificates of Insurance from ICs and Sub Contractors?
Are any autos used exclusively for business use?
Do any employees use a personal auto for business use?
Are any web based services offered?
Are credit card payments accepted?
Is there a Pollution Exposure?
Do you work more than 3 stories above the ground?
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Professional Liability
Describe Professional Services offered?
Desired Amount of Professional Liability Coverage ($)
Does your firm provide services outside the U.S.?
Yes
No
Percentage of Services for the outside the U.S
Is there a formal Safety Plan?
Yes
No
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
Are you requesting Medical Professional Liability Coverage?
Yes
No
Underwriting Questions
Rows
Yes
No
Do you request Certificates of Insurance from ICs and Sub Contractors?
Do you provide Professional Liability to your ICs and Sub Contractors?
Is there a Medical Director?
Does the Medical Director have their own insurance?
Do you employ Physicians or Surgeons?
Do you bill for Medicare/Medicaid?
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Workers' Compensation
Are you requesting Workers’ Compensation Coverage do to a contract requirement?
Yes
No
Number of Employees
Rows
Full-time
Part-time
Number of Employees
Number of Independent Contractors (ICs)
Rows
Full-time
Part-time
Number of Independent Contractors (ICs)
Are Medical Benefits Offered?
Yes
No
Do you offer Paid Vacation?
Yes
No
Is there a formal Safety Program?
Yes
No
Total Estimated Payroll ($)
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Commercial Auto
Driver(s) Details
Vehicle(s) Details
Policy Level Liability
Please Select
50/100/50
100/300/100
250/500/100
1million
Add-on Coverages
Hired and Non-Owned
Waiver of Subrogation
Additional Insured
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Effective Date for New Policy
-
Month
-
Day
Year
Date
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