Hereth Insurance Consulting
Business Packet
Business Name
DBA Name
Contact Name & Position
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
Phone
FEIN
Years in Business (If new, Years of Experience within Industry / Trade)
States Licensed/Operating In
Type of Business
Please Select
LLC
Sole Prop
Partnership
Corporation
Other
Attach copies of current policy documents
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Annual Payroll and Sales / Receipts
Rows
Current Year
Prior Year
Payroll
Sales / Receipts
Commercial vs Residential
Rows
Current Year
Prior Year
Commercial
Residential
Any claims in the past 5 years?
*
Yes
No
Faulty Construction Litigation?
*
Yes
No
Subcontractor Costs
*
Rows
Current Year
Prior Year
Costs
Do you have a Written Subcontractor Agreement?
Yes
No
N / A (no subcontractors are used)
Do you require Certificates of Insurance?
Yes
No
N / A (no subcontractors are used)
Are Subcontractor Limits less then yours?
Yes
No
N / A (no subcontractors are used)
Additional Insured on Subcontractors’ Policies?
Yes
No
N / A (no subcontractors are used)
Architect/Engineer Role When Not GC?
Yes
No
N / A (no subcontractors are used)
Jobsite Supervision Daily?
Yes
No
N / A (no subcontractors are used)
Hazard/Exposure Checklist (check all that apply):
Work Over 3 Stories
Work on Condos/Townhomes/Tract Housing
Use of Cranes
Bridges/Levees/Tunnels/Flood Control/Retaining Walls/Sea Work
Excavation/Tunneling/Underground/Earthmoving
Blasting/HazardousMaterials/Flammables
Swimming Pools
Snow Removal (Commercial)
Other
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Work by Type
Rows
Percentage
New Construction
Remodel & Alternations
Service & Maintenance
Work by Sector
Rows
Percentage
Commercial
Residential
General Liability: Exposures
Rows
Work
Performed
Class
Code
Employee
Payroll
Details
Details
Details
Property: Coverage & Details
Rows
Location #1
Location #2
Location #3
Location
Address
Building
Limit
Contents
Limit
SQFT
Roof
Update
Elec.
Update
Plumbing
Update
HVAC
Update
Inland Marine: Coverage & Details
Rows
Item #1
Item #2
Item #3
Blanket
Tool Limit
Description
Year
Make
Model
Serial
#
Value
Business Auto
Rows
Year
Make
Model
VIN
Radius
of Use
Comp
Ded
Collision
Ded
Vehicle 1
NONE
$250
$500
$1000
NONE
$250
$500
$1000
Vehicle 2
NONE
$250
$500
$1000
NONE
$250
$500
$1000
Vehicle 3
NONE
$250
$500
$1000
NONE
$250
$500
$1000
Driver Schedule
Rows
First
Name
Last
Name
DOB
VIN
DL#
State
Violations
(5 yrs)
Driver
Driver
Driver
Workers Compensation: Exposures
Rows
Class
Code
Description
of Work
Full Time
Part Time
Payroll
Code
Code
Code
Including or Excluding of Ownership from Workers Compensation
Rows
Name
Title
Duties
%
Owner
Inc/Exc
Payroll
Owner
Owner
Are there any other exposures or operations not covered above?
Submit
Should be Empty: