Business Insurance
*Please fill out the applicable sections to the coverage types being requested* Commercial Auto, General Liability, Property & Workers Comp
Client Information
Owner's Name
Title
Email
Phone
Business Information
Business Name
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Webpage
FEIN/TAX ID Number
Company Size
Please Select
1-10 Employees
10-50 Employees
50-100 Employees
over 100 employees
Type of Business
Please provide details of scope of work
Ex: Lawn Care & Maintenance - TN only. 50 mile radius. Regular mowing, edging, and trimming bushes. Aeration and overseeding. Leaf removal and yard cleanup. No fertilization/ weed control.
Years of Experience
Annual Revenue for the Business
*Not Profit - Money coming in the door only
Business Policy Attachment
Upload a File
Drag and drop files here
Choose a file
Cancel
of
List any claims details:
Date of claim, $ amount, what happened
Have you ever had an insurance policy non-renewal, cancelled, or declined?
Please Select
Yes
No
Have you ever been convicted of a crime of fraud, bribery, or arson?
Please Select
Yes
No
Any bankruptcies, tax or credit liens?
Please Select
Yes
No
Are there any additional insured's?
coverages
Select desired coverage's below
Commercial Auto
General Liability Coverage
Property
Workers Compensation
Total Number of Employees:
Annual Payroll:
Are subcontractors being used?
Please Select
Yes
No
Do they provide a copy of their insurance to work for you that you keep on file for 3 years?
Please Select
Yes
No
Annual subcontractor's cost:
Please describe the subcontractor's duties:
What carrier is your current policy insured with?
Is a Wavier of Subrogation or Additional Insured's required?
Enter who needs to be listed for Waiver of Subrogotation or Additional Insured
Property
If this does not apply to you - please leave blank.
Do you have an office location?
Please Select
Yes
No
Do you own or lease the building?
Please Select
Yes
No
Construction type of building and roof?
Does it have a monitored burglar or fire alarm?
Please Select
Yes
No
Does it have a sprinkler system?
Please Select
Yes
No
How much would it cost to replace all the property inside the building?
Fixtures, Inventory, Office Equipment, Furniture, etc.
Please describe any property claims in the last 5 years.
Commercial Auto
If this does not apply to you - please leave blank.
How many vehicles do you have?
Do employees take any vehicles home?
Garage Locations
Copy of Driver's list (include names, date of birth and driver license numbers), Copy of Vehicles List: Year, Make, Model and VIN#.
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Description of what vehicles are used for:
Describe any auto claims in the last 5 years:
Umbrella
If this does not apply to you - please leave blank.
Do you have a Commercial Umbrella?
Please Select
Yes
No
How much coverage do you think you need?
Workers compensation
If this does not apply to you - please leave blank.
List Owners and Payrolls for each. Do owners have a workers comp exclusion?
Have you had any claims? If Yes, Please give Description:
aDDITIONAL INFORMATION TO INCLUDE:
OPTIONAL:
Submit
Should be Empty: