Commercial Long Form "*" 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* MM slash DD slash YYYY Is the First Point of Contact an Owner?* Yes No First Point of Contact Ownership Percentage*Are There More Owners?* Yes No Additional Owner Details Owner Name Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. FEIN*SSN (If no FEIN)*Company/Organization Physical Address* Street Address 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 Your Company/Organization Physical Address Same as Your Mailing Address?* Yes No Company/Organization Mailing Address* Street Address 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 Entity Type* CORP LLC LP SOLE PROP OTHER Any Subsidiaries?* Yes No Description of Operations*Years of Experience (Owner)*Years in Business*Current Insurance Co*Expiration Date* MM slash DD slash YYYY 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 No Upload Your Contract Requirements Drop files here or Select files Max. file size: 39 MB. Any Losses Last Five Years?* Yes No Date, Description, and Estimate of Loss*Do You Have a Business Continuation Plan?* Yes No Is It Funded?* Yes No Would You Like to Discuss/Review Funding Plans?* Yes No Would You Like to Learn More About this Subject?* Yes No Coverage RequestedWhat Coverages Do You Need?*(Select All That Apply) General Liability Property Auto Workers Comp Errors and Omissions Cyber Directors and Officers Inland Marine Crime Umbrella Group Health Builders Risk Cargo Bond Executive Bonus Plans Other Other Coverage Details*Commercial General LiabilitySquare Footage You Occupy or Own*Do You Own or Lease Your Space* Own Lease Both Liability Limits Requested*1MM/2MM2MM/4MMAre You a Contractor or General Contractor?* Contractor General Contractor Neither Do You Use Sub Contractors?* Yes No 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*12345678910Any Waivers of Subrogation?* Yes No Description of Work*(Performed as Contractor or General Contractor)Do Employees Use Their Own Vehicles in the Business?* Yes No General Liability Additional Notes*Commercial PropertyHow Many Locations Do You Own or Lease?*Commercial Property Locations Address Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Commercial Property Additional NotesCommercial AutoDo You Have a Driver List File Available for Upload*YesNoCommercial Driver List Upload*Please drag and drop your driver list here Drop files here or Select files Max. file size: 39 MB. Commercial Driver List Name Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. VehiclesDesired Liability Coverage*300,000500,0001,000,0005,000,000Uninsured Motorist*Reject300,000500,0001,000,000Personal Injury Protection*Reject300,000500,0001,000,000Collision & Comp Deductibles*Reject500 Deductible1000 Deductible2500 DeductibleHired/Non-Owned Liability* Yes No Rental Reimbursement* Yes No Roadside* Yes No Do Any Vehicles Require "Filings"* Yes No Are All Vehicles Titled in the Name of Your Business* Yes No Title Variations*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* Yes No Commercial Vehicle List Upload Drop files here or Select files Max. file size: 39 MB. Commercial Vehicle List Make Model Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Commercial Auto Additional NotesWorkers CompensationOwner Information Name Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Does Your Business Have a Documented Safety Program?* Yes No Safety Program Documents Drop files here or Select files Max. file size: 39 MB. Employee/Payroll Category Employee Category Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Workers Comp Additional Notes*Errors and OmmissionsLimits of Liability*1,000,0002,000,0003,000,0004,000,0005,000,000Errors and Omissions Additional Notes*CyberDesired Limits of Liability*100,000250,000500,0001,000,0002,000,000Cyber Additional Notes*Directors and OfficersDesired Limits*1,000,0002,000,000Directors and Officers Additional Notes*Inland Marine Schedule - Mobile EquipmentDo You Have an Equipment List to Upload* Yes No Equipment List* Drop files here or Select files Max. file size: 39 MB. Equipment List Item Description Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Total Estimate Value of Misc. Tools/Equipment ea. Item Under $500*Inland Marine Additional NotesCrimeDesired Limits of Liability*100,000250,000500,0001,000,0002,000,000Crime Additional Notes*UmbrellaDesired Excess Liability Limits*1,000,0002,000,0003,000,0004,000,0005,000,000Deductible*2,5005,00010,000Umbrella Additional NotesGroup HealthCompany Desired Coverages* Major Medical Dental Vision Life Short Term Disability Long Term Disability Other Ancillary Coverages Employee Info Employee Name Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Employee Dependents Employee Name Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Group Health Additional Notes*Builders RiskOwner Name* First Last Builder Name* First Last Are You the Owner or Contractor* Owner Contractor Property Location Address* Street Address 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 Building Details Construction Type Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Inside City Limits* Yes No 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 No Construction Began When* MM slash DD slash YYYY Construction Start Date* MM slash DD slash YYYY Expected Completion Date* MM slash DD slash YYYY CargoCargo*25,00050,000100,000250,000500,0001,000,000+Describe the Cargo Carried*BondType of Bond*Bond Amount*Bond Additional Notes*CommentsThis field is for validation purposes and should be left unchanged.