Commercial Insurance Application
General Information
Applicant Name
*
First Name
Last Name
Company Name
Legal Entity
*
Individual
LLC
Partnership
Nonprofit
Email
*
Contact Number
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Detailed information about your business
*
0/500
FEIN
*
Number of employees
*
Including owner
Business established date
*
-
Month
-
Day
Year
Gross Annual Revenue ($)
*
Insurance coverage requested
*
General Liability
Commercial Property
Commercial Auto
Professional Liability
Workers' compensation
FEIN
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PROPERTY DETAILS
Do you have current insurance?
*
Yes
No
Current Carrier
Building Information
Construction Type
*
Please Select
fire-resistive
non-combustible
ordinary
heavy timber
wood-framed
other
Year Built
*
Insured sq feet
*
Year Renovated
*
Renovated Year
Roof
Electrical
Plumbing
Heating
Building Security
*
Local
Central
None
Fire Alarm
Burglar Alarm
Building Property Value ($)
*
Personal Property 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
Does you use Independent Contractors (ICs) or Sub Contractors?
*
Yes
No
Est. Annual Payroll for Subs ($)
*
Est. Annual Payroll Owners ($)
*
Underwriting Questions
*
Yes
No
Does you use Independent Contractors (ICs) or Sub Contractors?
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
Desired Amount of Professional Liability Coverage ($)
*
Describe Professional Services offered?
*
Does your firm provide services outside the U.S.?
*
Yes
No
Percentage of Services for the outside the U.S
*
Is there a formal Safety Plan?
*
Yes
No
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
What is the percentage of your firm’s gross Fees paid to ICs or Sub Contractors last year?
Are you requesting Medical Professional Liability Coverage?
Yes
No
Underwriting Questions
Yes
No
Do you request Certificates of Insurance from ICs and Sub Contractors?
Do you provide Professional Liability to your ICs and Sub Contractors?
Is there a Medical Director?
Does the Medical Director have their own insurance?
Do you employ Physicians or Surgeons?
Do you bill for Medicare/Medicaid?
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Workers' Compensation
Are you requesting Workers’ Compensation Coverage do to a contract requirement?
Yes
No
Number of Employees
Full-time
Part-time
Number of Employees
Number of Independent Contractors (ICs)
Full-time
Part-time
Number of Independent Contractors (ICs)
Are Medical Benefits Offered?
Yes
No
Do you offer Paid Vacation?
Yes
No
Is there a formal Safety Program?
Yes
No
Total Estimated Payroll ($)
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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
Current Insurance Carrier
Please list any additional details.
Submit
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