ASI BUSINESS QUOTE REQUEST

GENERAL BUSINESS INFO
Requested Effective Date

MonthDayYear
Date
Do you have a Federal Tax ID (FEIN) ?

YesNo - will use business DBA name
What is your business name?
Federal Tax ID# (FEIN)
How many owners are involved in the operating of the business?
How is your business setup?

Individual - No Federal EIN # from IRSPartnership - Multiple Owners per IRS and/or Secretary of StateCorporation - have Federal EIN from IRS and/or Secretary of State paperworkLLC - have Federal EIN from IRS and/or Secretary of State paperworkOther
If no FEIN#, what is your DBA Name?
Year Business started?
Business Physical Address
Address Line 1
Address Line 2
City
Street Address

Street Address Line 2

CityState

Zip Code
Zip Code
Business Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the business address the same as the mailing address?
- Business Mailing Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code

GENERAL BUSINESS INFO (cont...)
Check LA Secretary of State website for registration & named owners

Mandatory check for Workers Comp Quotes. Save copy to Server folder
Year Business Started?
Company Website
Scope of Operations / Business Description
Describe what do you do? What are typical jobs you complete? What state do you operate in? Hours of operation? How many years experience in this line of work? #Owners/Employees, Previous Ins? Subs?
Annual Estimated Gross Income/Sales
If you're unsure give us your best guess. This number is auditable.
Current / Expiring Company
Company on your Cert. of Insurance
Prior ins. in the past 3 years?
Annual Premium Budget
Ex: Would like a monthly payment of ($)?

OWNER INFO
Owner 1 Name

First NameLast NameSuffix
Phone Number

Area CodePhone Number
Birth Date

MonthDayYear
Date
Owner 1 SSN#
Your annual salary?
Owner 1
Email*
email is required to send Quotes
Permission to Text about Quotes*
Best Method to Reach you to Discuss your Option*

Phone CallEmailText MessageOther

Additional Owners
- Owner Info - 2
- Owner 2 Name
  
  First NameLast NameSuffix
- Phone Number
  
  Area CodePhone Number
- Birth Date
  
  MonthDayYear
  Date
- Owner 2 SSN#
- Your annual salary?
  Owner 2
- Email
  example@example.com
- Owner Info - 3
- Owner 3 Name
  
  First NameLast NameSuffix
- Phone Number
  
  Area CodePhone Number
- Birth Date
  
  MonthDayYear
  Date
- Owner 3 SSN#
- Your annual salary?
  Owner 3
- Email
  example@example.com
- Owner Info - 4
- Owner 4 Name
  
  First NameLast NameSuffix
- Phone Number
  
  Area CodePhone Number
- Birth Date
  
  MonthDayYear
  Date
- Owner 4 SSN#
- Your annual salary?
  Owner 4
- Email
  example@example.com
- Owner Info - 5
- Owner 5 Name
  
  First NameLast NameSuffix
- Phone Number
  
  Area CodePhone Number
- Birth Date
  
  MonthDayYear
  Date
- Owner 5 SSN#
- Your annual salary?
  Owner 5
- Email
  example@example.com

PAYROLL INFO

This if for owner's, current employees,and current 1099's. If you don't have any of the above currently, estimate what you plan to have during this policy period.

PAYROLL INFO
Total Annual Payroll for all Owners
For GL state minimum is currently $15,600. For WC: $44,200
# of Part Time Employees
How many during the year?
# of Full Time Employees
How many during the year?
Part Time Employees Payroll
Total Annual Part Time Payroll
Full Time Employees Payroll
Total Annual Full Time Payroll
Do you use 1099 Subcontractors?
Are subs insured?

SUBCONTRACTORS / 1099 CONTRACTORS
Do you use insured or uninsured subcontractors?

Insured Subs - have COI copy & limits match or exceed my coverageInsured Subs - have COI copy & limits are lower than my coverageUninsured SubsDon't Use Subs at all, ever
How much total do you pay out to your subs annually?

GENERAL QUESTIONS
Do you install, service, or demonstrate products?
Sell products under label of others?
Policy lapsed due to non payment in last 5 years?
Any hold harmless agreements, guarantees or warranties
Is any work performed over 15' or 2 stories in height?
Business promotional material comment about safety or security of premise?
If yes, please upload a copy
Do you lease employees to or from other employers? Or is there a labor interchange?
Involved in any other businesses?
Do you lease equipment to others without an operator?
Sponsor any social or sporting events?
Any past claims – sexual abuse, discrimination or molestation
Been involved in bankruptcy, foreclosure, arson, tax liens
Any operations sold, acquired or discontinued in last 5 years?
Any additional interest needed? {Landlord, Builders, Mortgagee etc.}
Is applicant a subsidiary of another entity
Any policy or coverage declined, cancelled or non-renewed during prior 3 years?
Any exposure to flammables, explosives or chemicals?
Is a formal safety program in operation?
You will need to upload a copy to submit to company
Copy of Formal Safety Program and/or Promo materials

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GENERAL LIABILITY

A standard insurance policy issued to business organizations to protect them against liability claims for bodily injury (BI) and property damage (PD) arising out of premises, operations, products, and completed operations; and advertising and personal injury (PI) liability.
If renting and/or required by contract, the minimum limits and requirements are usually found in the Insurance section of your lease and/or contract.
Do you need coverage?

Yes, I'd like a Quote - No Prior CoverageYes, I'd like a Quote - Current/Prior CoverageNo, Reject Coverage QuoteNo, I have coverage elsewhere

General Liability - Prior Coverage Info
Current Insurance Company (Not Agency)
Estimated Policy Expiration Date
Jan 2020 or 10-10-2020
Loss History for 3 years from prior company(ies)

Browse Files
Loss History (Loss Runs) will be required to bind new policy if you have had previous coverage. These should be requested from your current company and can be emailed to CL@allsaintsinsurance.com Cancelof
Previous GL Insurance Copy or Certificate of Insurance

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WORKERS COMPENSATION

Workers compensation insurance serves two purposes: It assures that injured workers get medical care and compensation for a portion of the income they lose while they are unable to return to work and it usually protects employers from lawsuits by workers injured while working.
Do you need coverage?

Yes, I'd like a Quote - No Prior CoverageYes, I'd like a Quote - Current/Prior CoverageNo, Reject Coverage QuoteNo, I have coverage elsewhere

WORKERS COMPENSATION
Coverage Limits Requested: Bodily Injury by Accident / Bodily Injury by Disease /Bodily Injury by Disease

$100,000 / $500,000 / $100,000$500,000 / $500,000 / $500,000$1,000,000 / $1,000,000 / $1,000,000
Do you want the owner(s) Included or Excluded from coverage?
Prior Coverage in last 3 years?
WC Loss History for the past 3 years and E-Mod Worksheet
WC Loss History for the past 3 years and E-Mod Worksheet

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If prior coverage exists this is required in order to quote Cancelof
Requested Policy Start Date

MonthDayYear
Date

Worker's Comp - Prior Coverage Info
Current Insurance Company (Not Agency)
Estimated Policy Expiration Date
Jan 2020 or 10-10-2020

COMMERCIAL PROPERTY

protects commercial property from such perils as fire, theft and natural disaster.
Do you need coverage?

Yes, I'd like a Quote - No Prior CoverageNo, Reject Coverage QuoteNo, I have coverage elsewhereYes, I'd like a Quote - Current/Prior Coverage

Property - Prior Coverage Info
Current Insurance Company (Not Agency)
Estimated Policy Expiration Date
Jan 2020 or 10-10-2020

BUSINESS AUTO

provides coverage for a company's use of cars, trucks, vans and other vehicles in the course of carrying out its business. Coverage may include vehicles owned or leased by the company, hired by the company, or employee-owned vehicles used for business purposes
Do you need coverage?

Yes, I'd like a Quote - No Prior CoverageYes, I'd like a Quote - Current/Prior CoverageNo, Reject Coverage QuoteNo, I have coverage elsewhere

Business Auto - Prior Coverage Info
Current Insurance Company (Not Agency)
Estimated Policy Expiration Date
Jan 2020 or 10-10-2020

GARAGE LIABILITY

A basic garage liability insurance policy is designed to cover bodily injury or property damage caused by an accident during garage business operations. Garage liability coverage is typically purchased by automobile dealerships and repair shops, among other businesses. A garagekeepers insurance policy protects you if a customer’s vehicle is damaged while it is at your business.
Do you need coverage?

Yes, I'd like a Quote - No Prior CoverageYes, I'd like a Quote - Current/Prior CoverageNo, Reject Coverage QuoteNo, I have coverage elsewhere

GARAGE LIABILITY
Liability

Auto Only - Accident
Liability

Other Than Auto - Accident
Aggregate

Other Than Auto
Please fill in the form below

Garage - Prior Coverage Info
Current Insurance Company (Not Agency)
Estimated Policy Expiration Date
Jan 2020 or 10-10-2020

INLAND MARINE / EQUIPMENT FLOATER

Equipment floater insurance is a form of property insurance that covers loss of or damage to equipment that is moved from one location to another
Do you need coverage?

Yes, I'd like a Quote - No Prior CoverageYes, I'd like a Quote - Current/Prior CoverageNo, Reject Coverage QuoteNo, I have coverage elsewhere

INLAND MARINE / EQUIPMENT FLOATER
Large Equipment over $500
Small Tools Total Insured Value:
For all individual items valued at less than $500/item
Deductibles

$500$1,000$2,000$2,500Other
Where are the tools / equipment stored when not in use?
enclosed trailer, garage, warehouse etc.

INLAND MARINE / EQUIPMENT FLOATER - Prior Coverage Info
Current Insurance Company (Not Agency)
Estimated Policy Expiration Date
Jan 2020 or 10-10-2020

UMBRELLA
Umbrella's Serve three purposes:
- It provides excess limits when the limits of underlying liability policies are exhausted by the payment of claims;
- it drops down and picks up where the underlying policy leaves off when the aggregate limit of the underlying policy in question is exhausted by the payment of claims; and
- it provides protection against some claims not covered by the underlying policies, subject to the assumption by the named insured of a self-insured retention (SIR).
Do you need coverage?

Yes, I'd like a Quote - No Prior CoverageYes, I'd like a Quote - Current/Prior CoverageNo, Reject Coverage QuoteNo, I have coverage elsewhere

UMBRELLA
Limits Requested:

$1,000,000$4,000,000$2,000,000$5,000,000$3,000,000$10,000,000+
Please fill in the form below

Umbrella - Prior Coverage Info
Current Insurance Company (Not Agency)
Estimated Policy Expiration Date
Jan 2020 or 10-10-2020

SUPPLEMENTALS

Artisan & Remodel Contractors

Builders Risk - Commercial

General Contractors

Any other questions or comments?

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BUSINESS QUOTE REQUEST

COVERAGE REQUESTED

GENERAL BUSINESS INFO

GENERAL BUSINESS INFO (cont...)

Check LA Secretary of State website for registration & named owners

OWNER INFO

Additional Owners

Owner Info - 2

Owner Info - 3

Owner Info - 4

Owner Info - 5

PAYROLL INFO

PAYROLL INFO

SUBCONTRACTORS / 1099 CONTRACTORS

GENERAL QUESTIONS

GENERAL LIABILITY

GENERAL LIABILITY

General Liability - Prior Coverage Info

WORKERS COMPENSATION

Worker's Comp - Prior Coverage Info

COMMERCIAL PROPERTY

COMMERCIAL PROPERTY - Location # 1

Property - Prior Coverage Info

COMMERCIAL PROPERTY - Location # 2

BUSINESS AUTO

Business Auto - Prior Coverage Info

GARAGE LIABILITY

GARAGE LIABILITY

Garage - Prior Coverage Info

INLAND MARINE / EQUIPMENT FLOATER

INLAND MARINE / EQUIPMENT FLOATER

INLAND MARINE / EQUIPMENT FLOATER - Prior Coverage Info

UMBRELLA

UMBRELLA

Umbrella - Prior Coverage Info

ADDITIONAL SUPPLEMENTAL INFO NEEDED

SUPPLEMENTALS

Artisan & Remodel Contractors

Builders Risk - Commercial

General Contractors

Any other questions or comments?

Click Submit below and you're all done!