Page 1 of 2
Personal Information
Name
*
First Name
Last Name
Date of birth
*
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Home phone number
*
Cell phone number
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*
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Personal email
*
example@example.com
Which is you preferred email?
*
Personal Email
Work Email
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your preferred method of contact?
*
Phone
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Page 2 of 2
Business Solutions
Type of Insurance Needed ?
*
Please Select
Commercial / Small Business Liability
Commercial Auto
EO / Professional Liability
Cyber Attack
Construction Liability / Builders Risk
Bonds / Inland Marine / Excess & Surplus / Other
Wind and Hail Policy
Flood Policies
Group Medical
Hotshot / Trucking
Rental Property Apartments
Rental Property Homes/Mobile Homes
Name of Business
*
Business EIN Number
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone Number.
*
Business Email.
*
example@example.com
Business Website Address.
*
Annual Gross Revenue
*
Nature of Business?
*
Please Select
Apartments
Condominiums
Contractors
Institutional / Education
Manufacturing
Office
Restaurant
Specialty Food
Online Services
Retail
Services
Wholesale
Garage / Auto Dealer
Child Care
NonProfit
Production
Trucking / Hotshot
Lawn Care / Landscaping
Fitness Instructors
Churches / Worship
Consultants
Other
Business Classification.
*
Please Select
Corporation
Individual
LLC
Joint Venture
Not for Profit
Partnership
Trust
Subchapter "S" Corporation
Date Business Started
*
-
Month
-
Day
Year
Date
Please describe business in detail.
List all properties needing insurance.
Name of current Insurance Carrier.
Please answer the following question.
These questions are needed to give an accurate quote.
Are areas leased to others?
*
Yes
No
Is a formal Safety Program in Operation?
*
Yes
No
Any Exposure to Flammable, Explosive or Chemicals?
*
Yes
No
Any policy or coverage declined, Cancelled or Non-Renewed?
*
Yes
No
ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED?
*
Yes
No
Number of Full Time Employees.
*
Number of Part Time Employees.
*
Has Business been placed in a Trust? If so please list here, mark NA for none.
*
Amount of Insurance Needed?
*
Any medical facilities provided, or medical professionals employed or contracted? If so please list here, mark NA for none.
*
Any exposure to radioactive/nuclear materials? If so please list here, mark NA for none.
*
Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material? (e.g., landfills, wastes, fuel tanks, etc.)If so please list here, mark NA for none.
*
Any operations sold, acquired, or discontinued in last five (5) years?If so please list here, mark NA for none.
*
Machinery or equipment loaned or rented to others?If so please list here, mark NA for none.
*
Any watercraft, docks, floats owned, hired or leased? If so please list here, mark NA for none.
*
Any parking facilities owned/rented? If so please list here, mark NA for none.
*
Is a fee charged for parking? If so please list here, mark NA for none.
*
Recreation facilities provided? If so please list here, mark NA for none.
*
Is there a swimming pool on the premises? If so please list here, mark NA for none.
*
Sporting or social events sponsored? If so please list here, mark NA for none.
*
Any structural alterations contemplated? If so please list here, mark NA for none.
*
Any demolition exposure contemplated?If so please list here, mark NA for none.
*
Has applicant been active in or is currently active in joint ventures? If so please list here, mark NA for none.
*
Do you lease employees to or from other employers? If so please list here, mark NA for none.
*
Is there a labor interchange with any other business or subsidiaries? If so please list here, mark NA for none.
*
Are day care facilities operated or controlled? If so please list here, mark NA for none.
*
Have any crimes occurred or been attempted on your premises within the last three (3) years? If so please list here, mark NA for none.
*
Does the businesses' promotional literature make any representations about the safety or security of the premises? If so please list here, mark NA for none.
*
Does applicant install, service or demonstrate products? If so please list here, mark NA for none.
*
Research and development conducted or new products planned? If so please list here, mark NA for none.
*
Guarantees, warranties, hold harmless agreements? If so please list here, mark NA for none.
*
Products related to aircraft/space industry If so please list here, mark NA for none.
*
Products recalled, discontinued, changed? If so please list here, mark NA for none.
*
Products of others sold or re-packaged under applicant label? If so please list here, mark NA for none.
*
Products under label of others? If so please list here, mark NA for none.
*
Vendors coverage required? If so please list here, mark NA for none.
*
Does any named insured sell to other named insureds? If so please list here, mark NA for none.
*
Has the business had a judgement or Lien during the last five (5) years? If yes please list here, if no place NA
*
Has the business had a foreclosure, repossession or files bankruptcy? If yes please list here if no place NA
*
Has the business had any uncorrectable fire or safety code violations? If yes please list here if no place NA
*
Has the business had any claims or loss due to sexual abuse or molestation allegations? If yes please list here if no place NA
*
During the last five years has anyone on the app been convicted of felony offensive? If yes please list here If no place NA
*
Please List all Individual who will be covered under policy with their title within the company. Please list yourself also.
*
Please upload the following: Current Insurance Policy, Loss History Report for 5 years, Last Submitted Taxes or Financial Statement,
*
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Authorization and Consent
Please read the attestations below and select a response. Information given is used by JDH Solutions PLLC, for the purposes of assessing eligibility for your quoting, binding, claims, underwriting, investigating, and auditing. YES to continue application, NO if you do not wish to move forward with your application.
I authorize JDH Solutions PLLC to collect and use my personal information for the sole purposes for my personalized insurance quote and binding. All information I have submitted is true and accurate to the best of my knowledge and I have not in any way submitted false, inaccurate, or misleading information on this application or any application submitted on my behave or my company. Any Person Who Knowingly and With Intent to Defraud Any Insurance Company or Another Person Files an Application for Insurance or Statement of Claim Containing Any Materially False Information or Conceals for The Purpose of Misleading Information Concerning Any Fact Material Thereto, Commits A Fraudulent Insurance Act, Which Is a Crime And Subjects The Person To Criminal And [Ny: Substantial) Civil Penal Ties. (Not Applicable in CO, FL, HI, MA, NE, OH, OK, OR VT. In DC, LA, ME, TN, VA and WA Insurance Benefits May Also Be Denied). In Florida, Any Person Who Knowingly and With Intent to Injure, Defraud, Or Deceive Any Insurer Files A Statement of Claim or An Application Containing Any False, Incomplete, Or Misleading Information Is Guilty of a Felony of The Third Degree.
*
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No
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