• Business Information:

  • Format: (000) 000-0000.
  • Is the person responsible for the insurance the same as the owner / contact above?*

  • Person responsible for the business insurance.

  • Format: (000) 000-0000.
  • Is the Business Physical Address the same as the Mailing Address?*

  • Insurance Quoting Information:

  • What Insurance Coverage(s) are you requesting? Please check all that apply

  • Worker's Compensation Quote Information

    Payroll Information:

    Underwriters require estimated annual payroll by class code, along with the number of employees assigned to each class code, in order to evaluate the exposure and issue a workers’ compensation quote.

    Company Payroll by State and Class Code. Include # of FT & PT Employees.

  • Does the company use Sub-Contractors (1099's)"
  • Do the Sub-Contractors have their own WC Policy?
  • Does the Total Company Payroll include the subcontractor payroll (1099)?

  • Owners and Officers Inclusion / Exclusion:

    Work Comp allows Owners and Officers to be excluded by choice.

  • Worker's Compensation Coverage Questions:

    The following questions are standard underwriting requirements used by all insurance carriers to evaluate and provide a workers’ compensation quote.

  • 1. Have you, in the past, present, or discontinued operations involved storing, treating, discharging, applying, disposing, or transporting hazardous material? (e.g. landfills, wastes, fuel tanks, etc.)*
  • 2. Is work performed underground or above 15 feet?*
  • 3. Is the applicant engaged in any other type of business?*
  • 4. Is a written safety program in operation?*
  • 5. Is there any group transportation provided?*
  • 6. Any employees under 16 or over 60 years of age?*
  • 7. Any seasonal employees?*
  • 8. Is there any volunteer or donated labor?*
  • 9. Any employees with physical handicaps?*
  • 10. Do any employees travel out of state?*
  • 11. Are physicals required after offers of employment are made?*
  • 12. Any prior coverage declined / cancelled / non-renewed in the last three (3) years? *
  • 13. Do any employees perform work for other businesses or subsidiaries?*
  • 14. Do you lease employees to or from other employers?*
  • 15. Do any employees predominantly work at home?*
  • 16. Any tax liens or bankruptcy within the last five (5) years? *
  • 17. Any undisputed and unpaid workers' compensation premium due from you or any commonly managed or owned enterprises? *

  • General Liability Quote Information

    Underwriters rate General Liability insurance using payroll and or revenue. Please provide the total annual revenue and payroll for the company.

     

  • Standard General Liability Limits are $1,000,000 (occurrence) / $2,000,000 (aggregate). Do you need higher limits?*
  • Does the company use Sub-Contractors (1099's)?*
  • Do the Sub-Contractors have their own WC Policy?
  • Do Subcontractors provide Certificates of Insurance?*
  • Do you Required to have your company named as Additional insured on the subcontractors policies?*
  • Do you obtain a Waiver of Subrogation?*
  • Do you Obtain a Hold Harmless Agreement?*
  • Do you verify that all hired subcontractors carry workers compensation insurance?*

  • Business Auto Quote Information

    Please input all of your vehicles and drivers.

  • ADD VEHICLES:

  • ADD DRIVERS:

  • Business Auto Insurance Questions.

    The questions below are required by underwriters to provide a quote.

  • Are MVR's checked on new drivers prior to hire?*
  • Is there a written driver training program?*
  • Is there a written distracted driver policy, including cell phones and other mobile devices?*

  • Inland Marine Insurance Questions.

    Equipment, machinery, tools, trailers, etc., are considered classed as Inland Marine for insurance purposes.  The questions below are required by underwriters to provide a quote.

  • Equipment / Tools Information

  • Add Equipment / Tools to the policy?*

  • Trailer(s) / Machinery Information

  • Add Trailer(s) / Machinery to the policy?*

  • Additional Interests or Lien Holder Information

     

  • Are there any additional interests or lien holders needed to be added?*

  • Umbrella / Excess Liability Information:

    Some contracts and companies require Umbrella or Excess Liability coverage.

     

  • Does your company or contracts require an Umbrella or Excess Liability policy?*

  • Secure File Upload:

    Please upload the following Document (if you have them):

    • Certificate of Insurance -   For the current policy term. Please include any endorsements needed for contractual purposes.
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