General Liability, Workers Comp, Crime Coverage
PREMIUM INDICATION
COMPANY INFORMATION
Company
*
Contact
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Revenues
*
# of Employees
*
# of Owners
*
Total Personnel
INSURANCE REQUESTED
We are interested in:
General Liability
Workers Compensation
Crime Coverage
GENERAL LIABILITY & PROPERTY
Office Space:
Tenate
Building Owner
Building Value
Building Sq Feet
Building Built
Construction
Please Select
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Modified Fire Resistive
Fire Resistive
Sprinkler System
Yes
No
Office Sq Feet
Personal Property
(Computers, furniture...)
Additional Locations?
Yes
No
Year of last Building Improvements
*
Requested General Liability Limit:
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Have you had a General Liability or Property Claim in the past 5 years?
Yes
No
General Liability or Property Claim(s) Information:
If you currently purchase this coverage, attach your policy Declarations Page
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of
WORKERS COMPENSATION
Annual Employee Payroll
(Not including owners)
Federal Tax ID Number
Is coverage desired for Owners?
Please Select
Yes
No
Annual Owner(s) Payroll
Have you had a Workers Compensation Claim in the past 5 years?
Yes
No
Workers Compensation Claim(s) Information:
CRIME COVERAGE
Scope of financial statement preparation:
Internal
CPA Compilation
CPA Review
CPA Audit
As it relates to physical checks, check all that apply:
Checks received are stamped "for deposit only"
Checks received are deposited daily
Our checks are locked in a safe place
Our check inventory is regularly counted
As it relates to computer controls, check all that apply:
Our software detects fraudulent usage
Passwords are changed regularly
Check writing functions are separated from check authorization
Dual authorization is required for all wire transfers
Wire transfers are always verified
Requested Liability Limit:
$250,000
$500,000
$1,000,000
$2,000,000
$3,000,000
$5,000,000
Requested Deductible:
$1,000
$2,500
$5,000
$10,000
$25,000
If you currently purchase this coverage, attach your policy Declarations Page
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: