"*" indicates required fields

Name of Business*

Website*

1st Point of Contact*

First Last

1st Point of Contact Email*

1st Point of Contact Office Number*

1st Point of Contact Mobile Number*

How Did You Find Us?*

Referral

Google

Social Media

Other

Referred By:*

First Name Last Name

Desired Effective Date*

Is the First Point of Contact an Owner?*

Yes

First Point of Contact Ownership Percentage*

Are There More Owners?*

Yes

Additional Owner Details

Owner Name	Actions

There are no Entries.

FEIN*

SSN (If no FEIN)*

Company/Organization Physical Address*

Street Address City State ZIP Code

Is Your Company/Organization Physical Address Same as Your Mailing Address?*

Yes

Company/Organization Mailing Address*

Street Address City State ZIP Code

Entity Type*

CORP

LLC

SOLE PROP

OTHER

Any Subsidiaries?*

Yes

Description of Operations*

Years of Experience (Owner)*

Years in Business*

Current Insurance Co*

Expiration Date*

Reason For Shopping Insurance*

Projected Annual Gross Receipts*

Projected Annual Payroll*

# Full Time Employees*

# Part Time Employees*

Do You Have Any Contract (Insurance) Requirements*

Yes

Upload Your Contract Requirements

Drop files here or

Max. file size: 39 MB.

Any Losses Last Five Years?*

Yes

Date, Description, and Estimate of Loss*

Do You Have a Business Continuation Plan?*

Yes

Is It Funded?*

Yes

Would You Like to Discuss/Review Funding Plans?*

Yes

Would You Like to Learn More About this Subject?*

Yes

Coverage Requested

What Coverages Do You Need?*

(Select All That Apply)

Other Coverage Details*

Commercial General Liability

Square Footage You Occupy or Own*

Do You Own or Lease Your Space*

Own

Lease

Both

Liability Limits Requested*

Are You a Contractor or General Contractor?*

Contractor

General Contractor

Neither

Do You Use Sub Contractors?*

Yes

Insured Sub Costs*

Uninsured Sub Costs*

Type of Work Subcontracted Out to Insured Subcontractors*

Type of Work Subcontracted Out to Uninsured Subcontractors*

% Residential Work*

% Commercial Work*

Any Additional Insureds*

Any Waivers of Subrogation?*

Yes

Description of Work*

(Performed as Contractor or General Contractor)

Do Employees Use Their Own Vehicles in the Business?*

Yes

General Liability Additional Notes*

Commercial Property

How Many Locations Do You Own or Lease?*

Commercial Property Locations

Address	Actions

There are no Entries.

Commercial Property Additional Notes

Commercial Auto

Do You Have a Driver List File Available for Upload*

Commercial Driver List Upload*

Please drag and drop your driver list here

Drop files here or

Max. file size: 39 MB.

Commercial Driver List

Name	Actions

There are no Entries.

Vehicles

Desired Liability Coverage*

Uninsured Motorist*

Personal Injury Protection*

Collision & Comp Deductibles*

Hired/Non-Owned Liability*

Yes

Rental Reimbursement*

Yes

Roadside*

Yes

Do Any Vehicles Require "Filings"*

Yes

Are All Vehicles Titled in the Name of Your Business*

Yes

Title Variations*

Identify the Vehicles Titled Outside of the Business and Who is on the Title for Each

Do You Have a Vehicle List File Available to Upload*

Yes

Commercial Vehicle List Upload

Drop files here or

Max. file size: 39 MB.

Commercial Vehicle List

Make	Model	Actions

There are no Entries.

Commercial Auto Additional Notes

Workers Compensation

Owner Information

Name	Actions

There are no Entries.

Does Your Business Have a Documented Safety Program?*

Yes

Safety Program Documents

Drop files here or

Max. file size: 39 MB.

Employee/Payroll Category

Employee Category	Actions

There are no Entries.

Workers Comp Additional Notes*

Errors and Ommissions

Limits of Liability*

Errors and Omissions Additional Notes*

Cyber

Desired Limits of Liability*

Cyber Additional Notes*

Directors and Officers

Desired Limits*

Directors and Officers Additional Notes*

Inland Marine Schedule - Mobile Equipment

Do You Have an Equipment List to Upload*

Yes

Equipment List*

Drop files here or

Max. file size: 39 MB.

Equipment List

Item Description	Actions

There are no Entries.

Total Estimate Value of Misc. Tools/Equipment ea. Item Under $500*

Inland Marine Additional Notes

Crime

Desired Limits of Liability*

Crime Additional Notes*

Umbrella

Desired Excess Liability Limits*

Deductible*

Umbrella Additional Notes

Group Health

Company Desired Coverages*

Major Medical

Dental

Vision

Life

Short Term Disability

Long Term Disability

Other Ancillary Coverages

Employee Info

Employee Name	Actions

There are no Entries.

Employee Dependents

Employee Name	Actions

There are no Entries.

Group Health Additional Notes*

Builders Risk

Owner Name*

First Last

Builder Name*

First Last

Are You the Owner or Contractor*

Owner

Contractor

Property Location Address*

Street Address City State ZIP Code

Building Details

Construction Type	Actions

There are no Entries.

Inside City Limits*

Yes

Distance to Fire Hydrant*

Distance to Fire Station*

Remodel or New Construction*

Remodel

New Construction

Pre Construction Value*

Year of Original Construction*

Description of Renovations*

Has Construction Begun*

Yes

Construction Began When*

Construction Start Date*

Expected Completion Date*

Cargo

Cargo*

Describe the Cargo Carried*

Bond

Type of Bond*

Bond Amount*

Bond Additional Notes*

This field is for validation purposes and should be left unchanged.