Modern Amenities // HUB International

Modern Amenities // HUB International

Insurance Program
General Business Information
Name:*

First NameLast Name
Title/Role:*
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.

Legal Business Name:*
Business Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business FEIN:*
Business Entity Type (Select One):*

CorporationLLCSole ProprietorOther
Years business was started: *
Desired Effective Date of New Policy: *

MonthDayYear
Date

General Liability (Required)
Estimated Annual Revenue (Gross): *
Number of business owners:*
Number of Employees/1099 contractors (Excluding Owners):*
Any incidents, claims, or lawsuits in the past 5 years:*

YesNo

Coverage for Machines and/or Inventory
Do any of the following apply to your machines/operations?*

The sale of tobacco products or hot beveragesVending Machines located outdoorsAutomatic Teller Machine (ATM) OperationsPhoto booth - rental, short or long termNone of the above
Have you experienced theft, vandalism, or equipment damage in the past 5 years?*

YesNo

Commercial Auto
Would you like a quote for Commercial Auto Insurance?*

YesNo
If yes - all fields are required for a quote.

If no - please skip this section.
Vehicle Schedule
Drivers Schedule
Any personal use of business vehicles?

YesNo
Any tickets, accidents, or losses in the last 5 years?

YesNo
Would you like Hired & Non-Owned Coverage

YesNo

Umbrella
Would you like a quote for a $1M umbrella?*

YesNo
Any contracts that require higher limits?*

YesNo

Workers Compensation
Business Owners (Full Names + date of Birth & % owned):*
Configurable list*
Any prior Workers' Comp claims:*

YesNo

Additional Insured Information
Please provide the appropriate information to add Property Manager and/or Property Owners as additional Insured (Full Name or Entity Name, Mailing Address, Email, and Phone Number). If this is not needed - please answer N/A:

Current Insurance Info
Do you currently carry business insurance?*

YesNo
Current Insurance Company?
Current Expiration Date:

MonthDayYear
Date
Current Premium:
Any coverage gaps or cancellations in the past 3 years?

YesNo

Other Coverage Line Quote Request
Would you like a quote on any of the coverages below?

Employee Practice LiabilityDirectors & Officers LiabilityCrimeCyberErrors & Omissions / Professional LiabilityOther

Questions/Comments:
Disclaimer and Acknowledgment
Modern Amenities - Insurance Requirements:

Commercial General Liability

Form: ISO CG 00 01 or broader, with per project aggregate
Limits:
$2,000,000 General Aggregate
$2,000,000 Products/Completed Operations Aggregate
$1,000,000 Personal & Advertising Injury
$1,000,000 Each Occurrence
$100,000 Fire Legal Liability
$10,000 Medical Payments

Commercial Automobile Liability

Coverage: Must cover all owned, hired, and non-owned vehicles used in the work
Limit: $1,000,000 Combined Single Limit

Workers’ Compensation

Limits:
$500,000 per accident
$500,000 per disease (policy limit)
$500,000 per employee

Additional Requirements
- Additional Insureds: All policies (except WC) must name:
  Property Owner // Property Manager
- Waiver of Subrogation: Required where legally allowed (except in cases of sole negligence or intentional misconduct of Owner)
- Residential Work: No policy shall exclude residential work
- Cancellation Notice: 30 days’ advance notice to Owner and Property Manager
I hereby certify that the information provided in this form is true, complete, and accurate to the best of my knowledge. I understand that any misrepresentation or omission may impact the underwriting process and could result in denial of coverage, cancellation of any issued policy, or denial of a claim.

Additionally, I acknowledge that if I choose not to request a quote for any required insurance listed above, I am responsible for securing the necessary coverage elsewhere to meet those requirements.

I acknowledge that completing this intake form does not guarantee coverage, and that coverage will not be effective until it is confirmed in writing by an authorized representative of the insurance carrier. I understand that additional underwriting information may be required, and that quotes are subject to review, eligibility, and final approval by the carrier.

I understand that this insurance program is offered through a licensed insurance broker, and that turnaround times for quotes may vary depending on the carrier and line of coverage. In general, quotes for most lines of coverage take 3–4 business days. Workers' compensation quotes typically take longer, with an estimated turnaround time of 8–10 business days.

By signing below, I authorize the broker or insurance representative to use the information provided to obtain quotes, negotiate terms, and communicate with insurance carriers on my behalf.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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Modern Amenities // HUB International

General Business Information

General Liability (Required)

Coverage for Machines and/or Inventory

Commercial Auto

Umbrella

Workers Compensation

Additional Insured Information

Current Insurance Info

Other Coverage Line Quote Request

Disclaimer and Acknowledgment