Business InformationName of Business(Required)Website(Required) 1st Point of Contact(Required) First Last Email(Required) Office Phone(Required)Mobile Phone(Required)FEIN(Required)SSN (if no FEIN)Entity Type(Required) Corporation LLC LP Sole Prop Other Any Subsidiaries?(Required) Yes No Description of Operations(Required)Reason For Shopping Insurance(Required)Years Experience(Required)Years in Business(Required)Current Carrier(Required)Expiration Date(Required) MM slash DD slash YYYY Annual Gross Revenue(Required)Annual Payroll(Required)# of Full Time Employees(Required)# of Part Time Employees(Required)Do you have any contract (insurance) requirements(Required) Yes No Any claims in last 5 years?(Required) Yes No Date, Description, and Estimate of Loss(s)(Required)Do you have a business continuation plan?(Required) Yes No Is it funded?(Required) Yes No Would you like to discuss/review funding plans?(Required) Yes No Would you like to learn more about this subject?(Required) Yes No Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is your mailing address the same as your physical address?(Required) Yes No Physical Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you find us?(Required) Referral Google Social Media Other Referral's Name First Last Desired Effective Date(Required) MM slash DD slash YYYY Is 1st Point of Contact the Owner?(Required) Yes No Percentage of Ownership(Required)Business Owner Contact InfoOwner Name(Required) First Last Email(Required) Phone(Required)Percentage of Ownership(Required)Are there more Owners?(Required) Yes No Additional Owner InfoAdditional Owner Name First Last Email(Required) Phone(Required)Percentage of Ownership(Required)Coverage RequestedCoverage Requested (Select all that apply):(Required) General Liability Property Auto Workers Comp E&O Cyber D&O Inland Marine Crime Umbrella Group Health Builders Risk Cargo Bond Other Other Coverage Details(Required)Please provide coverage details and limits requestedCommercial General LiabilitySquare Footage you occupy or own(Required)Do you Own or Lease your space(Required) Own Lease Both Liability Limits Requested(Required)1MM/2MM2MM/4MMAre you Contractor or General Contractor?(Required) Contractor General Contractor Neither Do you use Sub Contractors?(Required) Yes No Insured Sub Costs(Required)Uninsured Sub Costs(Required)Type of Work Subcontracted out to Insured Subcontractors(Required)Type of Work Subcontracted out to Uninsured Subcontractors(Required)% Residential work(Required)% Commercial Work(Required)Any Additional Insureds(Required)Any Waivers of Subrogation?(Required) Yes No Description of Work(Required)Performed as Contractor or General ContractorDo Employees use their own vehicles in the business?(Required) Yes No General Liability Additional Notes(Required)Commercial PropertyHow many locations do you own?Location Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this a Condo?(Required) Yes No Occupancy(Required) Owner Tenant Monitored Alarm?(Required) Local Monitored None Sprinklered?(Required) Yes No Building Value(Required)Tenants Improvements & Betterments(Required)Business Personal Property(Required)Square Footage(Required)How many stories?(Required)Year Built(Required)Construction Type(Required)FrameBrickStoneMetal/StealRoof Type(Required)CompositionTar/GravelMetalTileYear Roof Updated(Required)Year Electrical Updated(Required)Year Plumbing Updated(Required)Year HVAC Updated(Required)Commercial Property Additional NotesCommercial AutoHow many drivers do you have?(Required) 1 2 3 4 5 Do you have a Driver List file available for upload(Required) Yes No Driver List UploadMax. file size: 5 MB. Driver 1Name(Required) First Last License #(Required)License State(Required)Date of Birth(Required) MM slash DD slash YYYY CDL?(Required) Yes No Driver 2Name(Required) First Last License #(Required)License State(Required)Date of Birth(Required) MM slash DD slash YYYY CDL?(Required) Yes No Driver 3Name(Required) First Last License #(Required)License State(Required)Date of Birth(Required) MM slash DD slash YYYY CDL?(Required) Yes No Driver 4Name(Required) First Last License #(Required)License State(Required)Date of Birth(Required) MM slash DD slash YYYY CDL?(Required) Yes No Driver 5Name(Required) First Last License #(Required)License State(Required)Date of Birth(Required) MM slash DD slash YYYY CDL?(Required) Yes No VehiclesDesired Liability Coverage(Required)300,000500,0001,000,0005,000,000Uninsured Motorist(Required)Reject300,000500,0001,000,000Personal Injury Protection(Required)Reject300,000500,0001,000,000Collision & Comp Deductibles(Required)No500 Deductible1000 Deductible2500 DeductibleHired/non‐owned liability(Required) Yes No Rental Reimbursement(Required) Yes No Roadside(Required) Yes No Do any vehicles require "Filings"(Required) Yes No Are all vehicles titled in the name of your business(Required) Yes No Title Variations(Required)Identify the vehicles titled outside of the business and who is on the title for eachDo you have a vehicle list file available to upload(Required) Yes No Vehicle List(Required)Max. file size: 5 MB. How many vehicles(Required)12345Vehicle 1Year(Required)Make(Required)Model(Required)Radius(Required)VIN(Required)Trailer length (if applicable)Garaging Zip Code of Vehicle(Required)Value of Vehicle(Required)Permanently Attached Equipment Value (If Any)Vehicle 2Year(Required)Make(Required)Model(Required)Radius(Required)VIN(Required)Trailer length (if applicable)Garaging Zip Code of Vehicle(Required)Value of Vehicle(Required)Permanently Attached Equipment Value (If Any)Vehicle 3Year(Required)Make(Required)Model(Required)Radius(Required)VIN(Required)Trailer length (if applicable)Garaging Zip Code of Vehicle(Required)Value of Vehicle(Required)Permanently Attached Equipment Value (If Any)Vehicle 4Year(Required)Make(Required)Model(Required)Radius(Required)VIN(Required)Trailer length (if applicable)Garaging Zip Code of Vehicle(Required)Value of Vehicle(Required)Permanently Attached Equipment Value (If Any)Vehicle 5Year(Required)Make(Required)Model(Required)Radius(Required)VIN(Required)Trailer length (if applicable)Garaging Zip Code of Vehicle(Required)Value of Vehicle(Required)Permanently Attached Equipment Value (If Any)This field is hidden when viewing the formCommericial Auto Additional Notes SectionCommericial Auto Additional NotesWorkers CompensationOwner InfoName First Last DOB(Required) MM slash DD slash YYYY Title(Required)Note:If you choose to exclude owner from Worker's Comp benefits they must be at least 25% owner.*Note: If you choose to exclude owner from Worker's Comp benefits they must be at least 25% owner.Duties(Required)Ownership %(Required)Exclude(Required) Yes No Does your business have a documented Safety Program(Required) Yes No Safety Program DocumentsMax. file size: 5 MB. Employee/Payroll Category*Note: Employees Category Examples: Clerical, Driver, Technician, Retail, Electricians, HVAC, Plumbers, Artisan ContractorEmployee Category(Required)# Employees(Required)Payroll Category Total(Required)Workers Comp Additional NotesErrors and OmmissionsLimits of Liability(Required)1,000,0002,000,0003,000,0004,000,0005,000,000Errors and Ommissions Additional Notes(Required)CyberDesired Limits of Liability(Required)1,000,0002,000,000Cyber Additional Notes(Required)Directors and OfficersDesired Limits of Liability(Required)100,000250,000500,0001,000,0002,000,000Directors and Officers Additional Notes(Required)Inland MarineInland Marine Schedule - Mobile EquipmentDo you have an Equipment List to upload Yes No Equipment List(Required)Max. file size: 5 MB. Item Description(Required)Serial #(Required)Make/Model(Required)Item Value(Required)Total Estimate Value of Misc. Tools/Equipment ea. item under $500(Required)Example: hammers, drills, bits combined equal $2kInland Marine Addtional NotesCrimeDesired Limits of Liability(Required)100,000250,000500,0001,000,0002,000,000Crime Additional NotesUmbrellaDesired Excess Liability Limits(Required)1,000,0002,000,0003,000,0004,000,0005,000,000Deductible(Required)2,5005,00010,000Umbrella Additional NotesGroup HealthCompany Desired Coverages(Required) Major Medical Dental Vision Life Short Term Disability Long Term Disability Other Ancillary Coverages Other Ancillary Coverages typesWe require a Census. Choose your method(Required)Download the Excel File and UploadContinue Completing this formUpload Completed Census(Required)Max. file size: 5 MB. Employee InfoEmployee Name(Required) First Last Date of Birth MM slash DD slash YYYY Gender(Required)MaleFemaleWork Zip Code(Required)Home Zip Code(Required)Current Medicare Enrollee(Required)YesNoCurrent Cobra Or State Continuation(Required)YesNoShort Term Disability(Required) Yes No Long Term Disability(Required) Yes No Annual Salary + Commissions (If Any)(Required)Enrollment Type - Major Medical(Required)Employee OnlyEmployee + SpouseEmployee + ChildrenEmployee + FamilyEmployee WaivedEnrollment Type - Dental(Required)Employee OnlyEmployee + SpouseEmployee + ChildrenEmployee + FamilyEmployee WaivedEnrollment Type - Vision(Required)Employee OnlyEmployee + SpouseEmployee + ChildrenEmployee + FamilyEmployee WaivedFamilyDependentRelationship(Required)SpouseDomestic PartnerChildName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Home Zip(Required)Current Medicare Enrollee(Required)YesNoCurrent Cobra Or State Continuation(Required)YesNoThis field is hidden when viewing the formGroup Health Additional Notes SectionGroup Health Additional NotesBuilders RiskOwner Name(Required) First Last Builder Name(Required) First Last Are you the Owner or Contractor(Required) Owner Contractor Property Location Address(Required) Street Address City State / Province / Region ZIP / Postal Code How Many Buildings At This Location12345Building DetailsBuilding 1Cost of Labor(Required)Cost of Materials(Required)Construction Type(Required)FrameBrickStoneMetal/SteelRoof Type(Required)CompositionTar/GravelMetalTileNumber of Stories(Required)Square Feet(Required)Building 2Cost of Labor(Required)Cost of Materials(Required)Construction Type(Required)FrameBrickStoneMetal/SteelRoof Type(Required)CompositionTar/GravelMetalTileNumber of Stories(Required)Square Feet(Required)Building 3Cost of Labor(Required)Cost of Materials(Required)Construction Type(Required)FrameBrickStoneMetal/SteelRoof Type(Required)CompositionTar/GravelMetalTileNumber of Stories(Required)Square Feet(Required)Building 4Cost of Labor(Required)Cost of Materials(Required)Construction Type(Required)FrameBrickStoneMetal/SteelRoof Type(Required)CompositionTar/GravelMetalTileNumber of Stories(Required)Square Feet(Required)Building 5Cost of Labor(Required)Cost of Materials(Required)Construction Type(Required)FrameBrickStoneMetal/SteelRoof Type(Required)CompositionTar/GravelMetalTileNumber of Stories(Required)Square Feet(Required)This field is hidden when viewing the formSection BreakInside City Limits(Required) Yes No Distance to Fire Hydrant(Required)Distance to Fire Station(Required)Remodel or New Construction(Required) Remodel New Construction Pre Construction Value(Required)Year of original Construction(Required) MM slash DD slash YYYY Description of Renovations(Required)Has Construction Begun(Required) Yes No Construction began when(Required) MM slash DD slash YYYY Construction Start Date(Required) MM slash DD slash YYYY Expected Completion Date(Required) MM slash DD slash YYYY Flood Needed(Required) Yes No Mortgage CompanyBuilders Risk Additional Notes(Required)CargoDesired Limits of Liability(Required)25,00050,000100,000250,000500,0001,000,000+Describe the Cargo Carried(Required)BondType of Bond(Required)Bond Amount(Required)Bond Additional Notes (Required)
