PIAG Insurance - Business Policy Quote Form

1
Name of Insured Company* This field is required.(Complete legal name, please)
2
Effective Date* This field is required.
Date
Year
Month
Day
3
Type of Business* This field is required.
Individual
Partnership
Corporation
LLC
4
Federal ID Number
5
Physical Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Mailing AddressIf your mailing address is different from your physical address, fill out the below form. Otherwise, click NEXT.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Key Contact Person* This field is required.
First Name
Last Name
8
Key Contact Email* This field is required.
example@example.com
9
Key Contact Phone Number* This field is required.
Area Code
Phone Number
10
Key Contact Fax NumberIf applicable.
Area Code
Phone Number
11
Description of Business Operation* This field is required.
Huge
Large
Normal
Small
Ok
Ok
12
Hours of Operation* This field is required.
13
Years in Business* This field is required.
14
Annual Payroll* This field is required.
15
Annual Sales* This field is required.
16
Website* This field is required.
17
Number of Full Time Employees* This field is required.
18
Number of Part Time Employees* This field is required.
19
Number of Seasonal/1099 Employees* This field is required.
20
Do you have any reported losses in the last 3 years?* This field is required.
YESNO
21
What line(s) of coverage were the losses reported on?
BOP
WC
Auto
22
Are you looking to get a quote for BOP/Umbrella coverage?* This field is required.
YESNO
23
CoveragePlease enter any additional locations in a second form submission.
Location 1 - Limit
Location 1 - Deductible
Location 2 - Limit
Location 2 - Deductible
Building
Business Personal Property
Building
Business Personal Property
Location 1 - Limit
Location 1 - Deductible
Location 2 - Limit
Location 2 - Deductible
Location 1 - Limit
Location 1 - Deductible
Location 2 - Limit
Location 2 - Deductible
1 of 2
24
Coverages you would like to add...
Hired/Non-Owned Auto
Employee Benefits
Employment Practices Liability
Directors & Officers
Cyber/Data Breach
Errors & Omissions w/ Correction of Work
25
General Liability Limits
$1,000,00/$2,000,000
$2,000,000/$4,000,000
26
Umbrella Limits
$1,000,00
$2,000,000
$3,000,000
27
Building Year of Construction
28
Type of Construction
Frame
Masonry Non Combustible
Non Combustible
Joisted Masonry
29
Ownership Status
Owner
Tenant
30
Landlord Name
First Name
Last Name
31
Landlord Email Address
example@example.com
32
Landlord Phone Number
Area Code
Phone Number
33
Do you have an alarm system?
YESNO
34
Central?
Burglary
Fire
35
Central monitored by...If central is not monitored, please press NEXT.
36
Local?
Burglary
Fire
37
Do you have a sprinkler system?
YESNO
38
Distance to nearest fire station?
0 - 3 miles
3 - 5 miles
5+ miles
39
Fire hydrant within 1,000 feet?
YESNO
40
Total building square footage
41
Building square footage occupied only by you
42
Number of total stories in building
43
Year of most recent roof updates
44
Year of most recent wiring/electrical updates
45
Year of most recent plumbing updates
46
Year of most recent HVAC updates
47
Year of most recent other updates
48
Are you looking to get a quote for commercial auto coverage?* This field is required.
YESNO
49
Commercial Auto Information
Vehicle Make & Year
Vehicle ID Number (VIN)
Cost When New
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle Make & Year
Vehicle ID Number (VIN)
Cost When New
Vehicle Make & Year
Vehicle ID Number (VIN)
Cost When New
Vehicle Make & Year
Vehicle ID Number (VIN)
Cost When New
Vehicle Make & Year
Vehicle ID Number (VIN)
Cost When New
1 of 4
50
Would you like to add rental reimbursement?
YESNO
51
Would you like to add towing coverage?
YESNO
52
Collision/comp deductible?
$500
$1,000
$1,500
$2,000
53
DriversNOTICE - When carriers final quotes, they will run an MVR on employees. PIAG Insurance is not privy to the details listed, only the final numbers.
Full Legal Name
Date of Birth
Drivers License Number
State of License
Driver 1
Driver 2
Driver 3
Driver 4
Driver 1
Driver 2
Driver 3
Driver 4
Full Legal Name
Date of Birth
Drivers License Number
State of License
Full Legal Name
Date of Birth
Drivers License Number
State of License
Full Legal Name
Date of Birth
Drivers License Number
State of License
Full Legal Name
Date of Birth
Drivers License Number
State of License
1 of 4
54
Does the applicant obtain MVR verifications?
YESNO
55
Does the applicant have a specific driver recruiting method?
YESNO
56
Any drivers with moving traffic violations?
YESNO
57
Please explain the moving traffic violations.
Huge
Large
Normal
Small
Ok
Ok
58
Total Distance Traveled Daily
0 - 50 miles
50 - 150 miles
150 - 200 miles
59
Are you looking to get a quote for worker's comp coverage?* This field is required.
YESNO
60
Liability Limit
$1,000,000/$1,000,000/$1,000,000
$500,000/$500,000/$500,000
$100,000/$500,000/$100,000
61
What is your current WC deductible on policy, if applicable?
62
Experience Mod Rate
63
Payroll Questionnaire
Class Codes
Description
# of Full Time Employees
# of Part Time Employees
Annual Payroll
Class Codes
Description
# of Full Time Employees
# of Part Time Employees
Annual Payroll
Class Codes
Description
# of Full Time Employees
# of Part Time Employees
Annual Payroll
Class Codes
Description
# of Full Time Employees
# of Part Time Employees
Annual Payroll
Class Codes
Description
# of Full Time Employees
# of Part Time Employees
Annual Payroll
Class Codes
Description
# of Full Time Employees
# of Part Time Employees
Annual Payroll
Class Codes
Description
# of Full Time Employees
# of Part Time Employees
Annual Payroll
Class Codes
Description
# of Full Time Employees
# of Part Time Employees
Annual Payroll
Class Codes
Description
# of Full Time Employees
# of Part Time Employees
Annual Payroll
Class Codes
Description
# of Full Time Employees
# of Part Time Employees
Annual Payroll
1 of 9
64
Officers Roster
Name
Title
Class Code
% Ownership
Included or Excluded
Name
Title
Class Code
% Ownership
Included or Excluded
Name
Title
Class Code
% Ownership
Included or Excluded
Name
Title
Class Code
% Ownership
Included or Excluded
Name
Title
Class Code
% Ownership
Included or Excluded
Name
Title
Class Code
% Ownership
Included or Excluded
1 of 5
65
Are you certified as a drug free workplace?
YESNO
66
Do you do sub-contract work?
YESNO
67
At what percentage do you sub-contract?
68
Do you obtain COI's from all sub-contractors?
YESNO
69
Is a written safety/accident program in operation?
YESNO
70
Does your safety/accident program include an accident investigation plan?
YESNO
71
Does your safety/accident program include an active safety committee?
YESNO
72
Please describe your safety plan, if applicable.
Huge
Large
Normal
Small
Ok
Ok
73
Are any workers under 16 years of age or over 60 years of age?
YESNO
74
Are employees required to work 15 feet above the ground to perform their jobs?
YESNO
75
What is the maximum height?
76
Is there any volunteer or donated labor?
YESNO
77
To conduct business, do employees travel out of the country?
YESNO
78
Are employees required to wear personal protection gear to complete their work?
YESNO
79
Please describe what type of protection gear employees are required to wear.
Huge
Large
Normal
Small
Ok
Ok
80
How did you hear about PIAG Insurance?
81
Thank you! Please press submit to submit your quote request form.

You will receive a confirmation email with a copy of your answers to the email address you provided to the key contact email in section 1.
Should be Empty:

Thank you! Please press submit to submit your quote request form.

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