We do things a little different, our goal is to help protect you against everyday risks...
We ae going to ask you a few question to make sure we not only provide you with the correct coverage but that you also receive the best rate
Business Legal Name
*
Dba Name
Type of entity
*
Individual
LLC
Corporation
Partnership
Other
Fein # / Tax ID #
Number of years in business
Brief description of business activity
*
Contacts Name
*
First Name
Last Name
Contacts Title
Business Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contacts Phone #
*
-
Area Code
Phone Number
Contacts Email
*
example@example.com
Business Website?
How were you referred to our agency?
What lines of business are we quoting?
*
Commercial Auto 🚗
Business Owners Policy 🏡
General Liability 🏤
Workers Comp ⚠️
Inland Marine 🚂
Other
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Commercial Auto Info ~ 🚗
Contacts Name
*
First Name
Last Name
Prior Commercial Auto Insurance
1 year +
3 years +
5 years +
No Prior Insurance
No Need - New Business
Current Auto Carrier?
How is current policy paid?
Monthly
Quarterly
Bi-annually
Annually
What is current policy premium?
Current Liability Limits
50/100
100/300
250/500
300,000
500,000
1,000,000
2,000,000
Other Option
Medical Payments
$1,000
$2,500
$5,000
$10,000
$25,000
No Coverage
Roadside Assistance & Towing
Yes
No
Rental Car Coverage
$30 per day
$40 per day
$50 per day
$60 per day
No Coverage
Other Option
Hired Auto Coverage
Yes
No
Unsure
Requested Liability limits?
100/300
250/500
300,000
500,000
1,000,000
Requested additional coverages?
Medical Payments
Roadside/Towing
Rental car coverage
Hired Auto coverage
N/A
# of autos on the policy?
1
2
3
4
If more than 4 ask for a spreadsheet with info
Auto #1
Year
Make
Model
Vin #
Auto #1 Comprehensive Deductible
No Coverage
$100
$250
$500
$1000
$2500
$5000
Auto #1 Collision Deductible
No Coverage
$100
$250
$500
$1000
$2500
$5000
Auto #2
Year
Make
Model
Vin #
Auto #2 Comprehensive Deductible
No Coverage
$100
$250
$500
$1000
$2500
$5000
Auto #2 Collision Deductible
No Coverage
$100
$250
$500
$1000
$2500
$5000
Auto #3
Year
Make
Model
Vin #
Auto #3 Comprehensive Deductible
No Coverage
$100
$250
$500
$1000
$2500
$5000
Auto #3 Collision Deductible
No Coverage
$100
$250
$500
$1000
$2500
$5000
Auto #4
Year
Make
Model
Vin #
Auto #4 Comprehensive Deductible
No Coverage
$100
$250
$500
$1000
$2500
$5000
Auto #4 Collision Deductible
No Coverage
$100
$250
$500
$1000
$2500
$5000
Inland Marine coverage needed?
Yes
No
Unsure
(coverage for mobile tools, equipment, machinery)
Total # of drivers
1 driver
2 drivers
3 drivers
4 drivers
If more than 4 ask for spreadsheet with info
Driver #1
*
First Name
Last Name
Driver #1 Dob:
-
Month
-
Day
Year
Date
Driver #1 Drivers License #
Driver #2
*
First Name
Last Name
Driver #2 Dob:
-
Month
-
Day
Year
Date
Driver #2 Drivers License #
Driver #3
*
First Name
Last Name
Driver #3 Dob:
-
Month
-
Day
Year
Date
Driver #3 Drivers License #
Driver #4
*
First Name
Last Name
Driver #4 Dob:
-
Month
-
Day
Year
Date
Driver #4 Drivers License #
Do any drivers have violations in the past 3 years?
Yes
No
Unsure
Total # of violations?
1
2
3
More than 3
If more than 3 ask for spreadsheet with info
Violation #1 Info
Driver Name
Violation
Date of incident
Violation #2 Info
Driver Name
Violation
Date of incident
Violation #3 Info
Driver Name
Violation
Date of incident
Do any drivers have at fault accidents in the past 5 years?
Yes
No
Unsure
Total # of at fault accidents?
1
2
3
More than 3
If more than 3 ask for spreadsheet with info
Accident #1 Info
Driver Name
Violation
Date of incident
Accident #2 Info
Driver Name
Violation
Date of incident
Accident #3 Info
Driver Name
Violation
Date of incident
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Business Owners Policy Info ~🏡
Contacts Name
*
First Name
Last Name
Mailing Address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does Insured have current property insurance?
*
Yes
No
No Need
New Business
Current Property Insurance Carrier?
Current Policy premium?
Any property claims in past 5 years?
Yes
No
N/A
Description of property claims.
(include location, date and summary of claim)
Number of locations?
One
Two
Three
More than Three
If more than 3 ask for a spreadsheet with info
Is location #1 address the same as the mailing address
Yes
No
Location #1 Address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location #1 Building coverage amount?
Location #1 Business Personal Property coverage amount?
Requested Building coverage deductible?
$500
$1,000
$2,500
$5,000
Requested Business Personal Property coverage deductible?
$500
$1,000
$2,500
$5,000
Location #1 Tenants Improvements & Betterments coverage amount?
N/A
50,000
100,000
200,000
300,000
500,000
Business Income coverage amount?
Year Built
Number of stories?
1
2
3
4
more than 4
Total Building square footage?
Occupied square footage?
Building Construction
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Fire Resistive
Roof Type
Shingle
Tin
Metal
Tile
Rubber/Flat
Other
Roof Age (year roof was replaced)
*
How was the age of the roof verified?
Customer
Realtor
Inspection
Listing
Applicable Discounts
Central Burglar Alarm
Central Fire Alarm
Leak / Water Detection Sensors
Distance to nearest Fire Department?
1-5 miles
6-10 miles
11+
Distance to nearest Fire Hydrant?
0-500 feet
500-1000 feet
1000+ feet
Unsure
Is there a Mortgagee?
Yes
No
Is the premium escrowed?
Yes
No
Does the insured need protection from flood?
Yes
Customer Declined
Location #2 Address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location #2 Building coverage amount?
Location #2 Business Personal Property coverage amount?
Requested Building coverage deductible?
$500
$1,000
$2,500
$5,000
Requested Business Personal Property coverage deductible?
$500
$1,000
$2,500
$5,000
Location #2 Tenants Improvements & Betterments coverage amount?
N/A
50,000
100,000
200,000
300,000
500,000
Business Income coverage amount?
Year Built
Number of stories?
1
2
3
4
more than 4
Total Building square footage?
Occupied square footage?
Building Construction
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Fire Resistive
Roof Type
Shingle
Tin
Metal
Tile
Rubber/Flat
Other
Roof Age (year roof was replaced)
*
How was the age of the roof verified?
Customer
Realtor
Inspection
Listing
Applicable Discounts
Central Burglar Alarm
Central Fire Alarm
Leak / Water Detection Sensors
Distance to nearest Fire Department?
1-5 miles
6-10 miles
11+
Distance to nearest Fire Hydrant?
0-500 feet
500-1000 feet
1000+ feet
Unsure
Is there a Mortgagee?
Yes
No
Is the premium escrowed?
Yes
No
Does the insured need protection from flood?
Yes
Customer Declined
Location #3 Address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location #3 Building coverage amount?
Location #3 Business Personal Property coverage amount?
Requested Building coverage deductible?
$500
$1,000
$2,500
$5,000
Requested Business Personal Property coverage deductible?
$500
$1,000
$2,500
$5,000
Location #3 Tenants Improvements & Betterments coverage amount?
N/A
50,000
100,000
200,000
300,000
500,000
Business Income coverage amount?
Year Built
Number of stories?
1
2
3
4
more than 4
Total Building square footage?
Occupied square footage?
Building Construction
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Fire Resistive
Roof Type
Shingle
Tin
Metal
Tile
Rubber/Flat
Other
Roof Age (year roof was replaced)
*
How was the age of the roof verified?
Customer
Realtor
Inspection
Listing
Applicable Discounts
Central Burglar Alarm
Central Fire Alarm
Leak / Water Detection Sensors
Distance to nearest Fire Department?
1-5 miles
6-10 miles
11+
Distance to nearest Fire Hydrant?
0-500 feet
500-1000 feet
1000+ feet
Unsure
Is there a Mortgagee?
Yes
No
Is the premium escrowed?
Yes
No
Does the insured need protection from flood?
Yes
Customer Declined
Inland Marine coverage needed?
Yes
No
Unsure
(coverage for mobile tools, equipment, machinery)
Notes about Building or Business Personal Property:
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General Liability Info ~ 🏤
Contacts Name
*
First Name
Last Name
Mailing Address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Detailed Business Description?
(include date and summary of claim)
Is there current insurance in place?
Yes
No
New Business
Prior Liability Carrier?
Prior Liability premium?
Any losses in past 5 years?
Yes
No
Description of losses?
Gross Sales/Receipts?
(Estimate if new business)
Total Estimated annual payroll?
(Direct employees only)
Number of Employees?
Are subcontractors / independent used?
Yes
No
Do you request certificates of insurance from them?
Yes
No
Total cost / payroll for subcontractors
Are there additional insureds that need listed on the policy?
Yes
No
Additional Insureds info?
(name, address, as it should appear on Certificate of Insurance)
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Workers Comp ~ ⚠️
Contacts Name
*
First Name
Last Name
Business Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of locations?
One
Two
Three
More than Three
If more than 3 ask for a spreadsheet with info
Is location #1 the same as the mailing address?
Yes
No
Location #1 Address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location #2 Address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location #3 Address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
# of Full Time Employees?
Estimated payroll of full time employees?
Job Descriptions of Full Time employees?
# of Part Time Employees?
Estimated payroll of part time employees?
Job Descriptions of Part Time employees?
Does the business have a website?
Yes
No
Website address?
Requested limits?
per occurrence
per employee
policy limits
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Inland Marine ~ 🚂
Type of coverage needed?
Unscheduled
Scheduled
Brief Description of Items to be covered?
(mobile tools, equipment, machinery)
Value of unscheduled items?
# of items to be scheduled
1
2
3
4
(if more than 4 ask for a spreadsheet listing items, year, make, model, serial #, value)
Item #1
Year
Make
Model
Serial #
Value
Item #2
Year
Make
Model
Serial #
Value
Item #3
Year
Make
Model
Serial #
Value
Item #4
Year
Make
Model
Serial #
Value
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Notes:
This document will become a permanent record in this client's file. Underwriting and coverage decisions by our sales, service team, and carriers will rely on this information to be accurate. B initialing below, you acknowledge that all the information included with this document is accurate and was provided to you by the client.
Initials:
Additional Notes:
Submit
Should be Empty: