• Contact

  • Format: (000) 000-0000.
  • Many clients prefer to receive quote and policy updates by text.

  • Business Information

  • Is the physical location the same as the mailing address?*
  • Do you use subcontractors?*
  • Do your subcontractors carry their own insurance?*

  • Coverage Needed

  • Coverage Needed*
  • Desired Effective Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • General Liability

  • Does the business sell, manufacture, or distribute products?*
  • Is work performed at clients' locations or job sites?*
  • Are any hazardous materials used or stored?*

  • Workers' Compensation

  • Employee payroll table*
  • Owners / officers table*
  • Date of birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are any employees under 16 or over 60 years old?*
  • Any seasonal employees?
  • Is any work performed out of state?*
  • Do any employees travel out of state for work?

  • Commercial Property

  • Do you own or rent the building?*
  • Is the building sprinklered?

  • Commercial Auto

  • Vehicles*
  • Drivers*
  • Do employees use personal vehicles for business?*
  • Do you haul for others or require federal/state filings?*

  • Umbrella

  • Current Insurance & Loss History

  • Do you currently have business insurance?*
  • Current carrier(s)
  • Any claims or losses in the past 5 years?*
  • Claims or losses details
  • Any insurance cancelled or non-renewed in the past 3 years?*

  • Documents

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  • Current policy expiration date
     - -
    2 digit month, 2 digit day, 4 digit year

  • A few underwriting questions

  • Is the business owned by, or does it own, another company?
  • Do you have a written safety program?
  • Do you store or use flammables, explosives or chemicals?
  • In the past 5 years, has any owner been convicted of fraud, bribery or arson?
  • Any uncorrected fire code violations?
  • Any bankruptcy, foreclosure, tax lien or judgment in the past 5 years?
  • Do you own, lease or hire others to operate drones?
  • Any other business ventures not covered by this application?

  • Authorization

  • I confirm the information provided is accurate to the best of my knowledge and authorize Legacy Partners Insurance Agency to share it with insurance companies to obtain quotes, including loss history and other reports where permitted.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: