Commercial Intake

COMMERCIAL INTAKE
Welcome! Let's get you covered.

Details up front let me shop carriers, catch gaps, and get you a real quote — without the endless back and forth.
- Skip anything that doesn't apply.
- Save and come back anytime.
- Nice to have ready: your dec pages and loss runs (your agent or carrier can email loss runs if you need them).
- About 20 to 30 minutes.
Thanks for taking the time. It pays off in better coverage!
Business Information
Legal business name
DBA (doing business as)
Mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address the same as your physical address?
Physical address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your primary location a home office or home-based business?
Business phone
Please enter a valid phone number.Format: (000) 000-0000.
Website
FEIN or SSN
SIC code (if known)
NAICS code (if known)
Entity type
Date business started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Years of industry experience
State(s) of operation
Radius of operations from main location (in miles)

Contacts

Rows	Name	Email	Phone
Primary
Inspections
Accounting
Claims

Owners, officers, partners, and relatives in business
Licenses
Would you like general liabilty coverage quoted?
Would you like workers comp coverage quoted?
Would you like commercial auto coverage quoted?
Would you like business property coverage quoted?
Would you like builders risk coverage quoted?
Would you like umbrella/excess coverage quoted?

Operations
Nature of business and primary operations
Do you provide services, products, or both?
Where is work performed?
Number of additional insured endorsements expected this year

Your role on projects

Rows	% of role - should total to 100
General contractor
Subcontractor
Construction manager
Developer
Other

Type of work (NC=New construction, RM=Remodeling)

Rows	% of work - should total to 100
NC Industrial (factories, plants, warehouses)
NC Institutional (schools, hospitals, churches, government buildings)
NC Mercantile (stores, shops, showrooms, malls)
NC Office (office buildings)
NC Single family (detached homes: custom, tract, or spec)
NC Multi-family (apartments, condos, townhouses)
RM commercial – Structural (work on load-bearing walls, framing, or foundations)
RM commercial – Non-structural (drywall, paint, flooring, finishes, cosmetic)
RM residential – Structural (work on load-bearing walls, framing, or foundations)
RM residential – Non-structural (drywall, paint, flooring, finishes, cosmetic)
Other (anything not listed above)

Historical financials (last 5 years)

Rows	Dates	Gross sales	Insured sub cost	Uninsured sub cost	Payroll
1st prior year
2nd prior year
3rd prior year
4th prior year
5th prior year

Average dollar value of a completed job

Three largest projects underway or planned for the next year

Rows	Address	Start date	End date	Value	Description
Project 1
Project 2
Project 3

Four largest projects over the past five years

Rows	Address	Start date	End date	Value	Description
Project 1
Project 2
Project 3
Project 4

General Liability
General liability coverage requested
Estimated gross sales by activity (next 12 months)

Workers Compensation
Workers compensation coverage requested (BI=Bodily injury)
Payroll by classification
Are owners, officers, partners, or relatives included or excluded from the policy?

Auto
Auto coverage requested
Vehicles
Drivers

Property
Locations and use
Business equipment and tools

Builders Risk
Your role on these projects
Builders risk projects

Umbrella
Umbrella/excess coverage requested

Insurance and Loss History

Current and expiring coverage

Rows	Current carrier	Expiration date	Years with carrier
General liability
Workers compensation
Commercial auto
Property
Umbrella/excess
Builders risk

Any claim or occurrence in the last five years?
If yes, list below

Documents to Upload
Declaration pages for current policies (all lines)

Cancelof
Loss runs for the last three to five years

Cancelof

Rows	Yes	No	If yes, please explain
Is the applicant a subsidiary of another entity?
Does the applicant have any subsidiaries?
Has the business been placed in a trust?
Does the applicant have other business ventures or operations not covered by this application?
Is coverage in place elsewhere for any of those other operations?
Any operations sold, acquired, or discontinued in the last five years?
Any foreign operations, or US products sold or distributed in foreign countries?
Does the applicant draw plans, designs, or specifications for others?
Do you employ any licensed architects, surveyors, engineers, or real estate agents or brokers?

Rows	Yes	No	If yes, please explain
Is a formal safety program in place (safety manual, safety officer, monthly meetings, OSHA)?
Any exposure to flammables, explosives, or chemicals, or any stored on site?
Do any operations use, store, or transport explosives, or include blasting?
Any uncorrected fire or safety code violations?
Any exposure to radioactive or nuclear materials?
Do operations involve storing, treating, discharging, applying, disposing, or transporting hazardous materials?

Rows	Yes	No	If yes, please explain
Does the applicant install, service, or demonstrate products?
Foreign products sold, distributed, or used as components?
Any guarantees, warranties, or hold harmless agreements given?
Products related to the aircraft or space industry?
Any products recalled, discontinued, or changed?
Products of others sold or repackaged under your label, or your products sold under another label?
Is vendors coverage required?
Does any named insured sell to another named insured?

Rows	Yes	No	If yes, please explain
Any medical facilities provided, or medical professionals employed or contracted?
Any watercraft, docks, or floats owned, hired, or leased?
Any parking facilities owned or rented?
Is a fee charged for parking?
Any recreation facilities provided?
Any lodging operations, including apartments?
Is there a swimming pool on the premises?
Are social events sponsored?
Are athletic teams sponsored?
Do you rent, lease, or loan equipment to others, with or without operators?
Do you lease or rent mobile equipment from others?

Rows	Yes	No	If yes, please explain
Do you or your employees visit job sites?
Do any employees use personal vehicles for business?
Do any employees take company vehicles home?
Are any drivers not employees?
Any delivery, transport, or mobile services?

COMMERCIAL INTAKE

Business Information

Operations

General Liability

Workers Compensation

Auto

Property

Builders Risk

Umbrella

Insurance and Loss History

Documents to Upload

Underwriting Questions

Acknowledgments

Rows	Yes	No	If yes, please explain
Any group transportation provided for employees?
Any seasonal employees?
Is there any volunteer or donated labor?
Do employees travel out of state?
Are physicals required after an offer of employment is made?
Are employee health or benefit plans provided?
Do any employees perform work for other businesses or subsidiaries?
Do you lease employees to or from other employers?
Do any employees predominantly work from home?
Do you use any casual labor?
Are you responsible for benefits for any casual or leased employees?
Any employees under 16 or over 60 years of age?
Any employees whose physical condition may affect the work they perform?

Rows	Yes	No	If yes, please explain
Do you require written subcontractor agreements?
Do all subcontractor contracts contain a hold harmless in your favor?
Do you collect certificates of insurance from subcontractors (always, sometimes, or never)?
Do subcontractors carry coverage limits equal to or greater than yours?
Are subcontractors ever allowed to work without providing a certificate of insurance?
Do you normally use the same subcontractors?

Rows	Yes	No	If yes, please explain
Do operations include excavation, tunneling, underground work, or earth moving?
Does any construction management work involve supervising subs whose contracts and payments are not under your direct control?
Any prior or planned jobs covered under wrap up or OCP policies?
Have you ever been, or are you currently, involved in any residential project exceeding twenty homes or units?
Have you done, or do you plan, work for refineries, chemical plants, railroads, public utilities, gas stations, airports, or hospitals?
Have you done, or do you plan, any project involving caissons, retaining walls, underpinning, piers, shoring, or other structural engineering?
Have you done, or do you plan, any work above two stories in height (if yes, percentage and maximum height)?
Have you done, or do you plan, any work below ground level (if yes, percentage and maximum depth)?
Have you done, or do you plan, any work on hillsides, hilltops, slopes, or landfills?
Do you do, or plan, any repair, replacement, or new roofing (if yes, percentage heat applied and percentage membrane)?
Have you performed, or do you perform, repairs of fire, water, or mold damage?
Any structural alterations or demolition contemplated?

Rows	Yes	No	If yes, please explain
Any policy or coverage declined, cancelled, or non renewed in the prior three years?
Any past losses or claims relating to sexual abuse or molestation, discrimination, or negligent hiring?
In the last five years, has any applicant been indicted for or convicted of fraud, bribery, arson, or any arson related crime?
Any foreclosure, repossession, or bankruptcy, or any bankruptcy filing, in the last five years?
Any tax liens in the last five years?
Any undisputed and unpaid workers compensation premium due from you or any commonly owned enterprise?
In the past three years, have you been fired or replaced on a job in progress?
Have you replaced another contractor on a job in progress?
Any suits brought against you in the last five years not already listed under loss history?
Do any persons or entities named in this application know of any act, error, omission, condition, or damage that may give rise to a future claim?
Have you been accused of faulty construction in the past five years?
Have you been accused of breaching a contract in the last five years?