Commercial Insurance - Business Owner's Application

Customer Information

What is the name that the insurance will be under (AKA What will be the Named Insured)?*

If you do not have a company, the name on the policy needs to match the name you are using for your vendors, permit offices or any other contracts that you have.

What type of entity is this insurance going to be for?*

Mailing Address*

Street Address City State ZIP Code

Contact Person*

First Last

Email*

Enter Email Confirm Email

Phone*

Please enter your Tax ID number*

What date do you want this policy to start?*

When was this business established?*

Please provide at least the month and year.

How many employees do you have?*

How much do you pay your employees annually?*

Do you hire contractors or subcontractors (i.e. 1099 workers) to execute tasks for you?*

Yes
No

Approximately how many contractors/subcontractors do you hire annually?*

Approximately how much do you pay contractors/subcontractors annually?*

What kinds of tasks do contractors/subcontractors execute for you, typically?*

Do your contractors/subcontractors name you as additional insured on their General Liability coverage?*

Yes
No

What are your gross annual sales receipts (or projected, if this is a new venture)*

What is the highest income you anticipate to make from a single client in the upcoming year?*

Please provide a precise description of your business operations:*

The more detailed you can be here, the better.

Does your business service, install or demonstrate any goods or products?*

Yes
No

Is your company in the business of selling goods/products?*

Yes
No

Will you require Vendor coverage?*

Yes, I will be acting as a vendor for other businesses
Yes, other businesses will act as a vendor to me
Yes, I both act as a vendor to other businesses, and other businesses act as a vendor to me
No, I will not require vendor coverage

Do you sell goods/products on a retail or wholesale basis?*

Wholesale
Retail
Both

What kinds of goods/products do you sell?*

Does your company import any products or materials?*

Yes
No

Please provide details for imported products and/or materials.*

Please include the percentage of materials and\or products that you import as well as the country of origin.

Does your business:*

Manufacture its own goods/products
Have others manufacture goods/products for your business
Repackage/rebrand products of others under your own company's label
None of the Above

Is reasearch and development of products conducted or are new products planned?*

Yes
No

Are any products related to the aircraft/space industry?*

Yes
No

Have any products been recalled, discontinued or changed?*

Yes
No

Do you design the products that others manufacture for you?*

Yes
No

Are you authorized to repackage/rebrand these products by the manufacturer?*

Yes
No

Please list the goods/products you manufacture, have manufactured for you, or repackage/relabel:*

Are there guarantees, warranties or hold harmless agreements in place?*

Yes
No

Is your company office based or service based?*

Office Based
Service Based
Both

Office based is ONLY office based. If you have business operations outside of your location please select Service or Both.

Will there be any exposure to radioactive/nuclear material?*

Yes
No

Are there any past. present or discontinued operations involving the storage, treatment, discharging, applying, disposing or transporting of hazardous materials? (e.g. landfills, wastes, fuel tanks, etc.)*

Yes
No

Do you rent or loan equipment to others?*

Yes
No

What kind of equipment do you rent/loan out to others?*

How much in revenue do your rental/loan out operations gross annually (if this is a new venture, please supply an anticipated figure)?*

Any watercraft, docks, or floats that are owned hired or leased?*

Yes
No

Are there any parking facilities owned or rented?*

Yes
No

Is a fee charged for parking?*

Yes
No

Are social events sponsored?*

Yes
No

Are atheltic teams sponsored?*

Yes
No

Are you seeking coverage for an apartment building/complex you own/are buying?*

Yes
No

Number of Apartment Units*

Square footage of the building(s)*

Are there any:*

Swimming Pools
Hot Tubs
Both
Neither

Check all that apply to the swimming pools/hot tubs' features:

Fully fenced
Limited access
Diving Board
Slide
Above Ground
In Ground
Life Guard
Life Safety Equipment

What kind of parking do tenants have access to:*

Tuck-Under Parking
Subterranean Parking Garage
Carports
Open Parking Lot
Gated/Fenced Parking Lot
Street Parking Only

Is there gated access?*

Yes - Code/card-activated gate
Yes - manual lock and key gate
No gated access

Laundry Facilities?*

Yes - Third Party Operated
Yes - Owner Operated
No

Are recreational facilities provided? (e.g. playgrounds, business centers, community gyms or clubhouses)*

Yes
No

Are there any other types of lodging operations? (e.g. short term rentals, hotel or motel operations)*

Yes
No

Are any medical facilities provided or medical professionals employed or contracted?*

Yes
No

Have any operations been sold, acquired or discontinued in the last five years?*

Yes
No

Do you own 50% or more of any other business?*

Yes
No

How many other businesses do you have more than a 49% ownership stake in?*

Is(Are) your other business(es) set up as a separate LLC/Corp./Non-Profit, etc.?*

Yes
No

Do any of your other businesses share the same ownership structure as the business you're currently seeking a quote for?*

Yes
No

Do any of the other businesses you own share the same operations as the business you're currently seeking a quote for?*

Yes
No

Please advise the names of your other businesses and provide a description of their business operations:*

Do your other businesses have their own insurance coverage?*

Yes
No

Is there a labor interchange with any other business or subsidiary?*

Yes
No

Do you lease employees to or from other employers?*

Yes
No

Is this a home-based business?*

Yes
No

Meaning that the business operations are executed entirely from a home office.

Are day care facilities operated or controlled?*

Yes
No

Have any crimes occurred or been attempted on your premises within the last three years?*

Yes
No

Is there a formal, written safety and security policy in effect?*

Yes
No

Does the business' promotional literature make any representations about the safety or security of the premises?*

Yes
No

Does your business use a written contract or statement of work?*

Yes
No

Do you or the principle of your firm maintain current and valid professional training, certifications, licenses or designations for all services you provide?*

Yes
No

Please provide a list of the current training, certifications, licenses or designations that the business and/or its principle carries*

Do your employees/workers use their own vehicles to execute tasks for the business?*

Yes
No

How many employees will be using their own vehicles to execute tasks for the business?*

How often do your employees use their own vehicles to execute tasks for the business?*

Daily
Weekly
Once a month
Every few months
Less than a few times a year

Does your business ever rent vehicles to execute business operatoins?*

Yes
No

How much do you anticipate spending annually to rent/hire vehicles?*

Prior Insurance / Claims

Any prior insurance?*

Yes
No

Please provide the policy numbers, premiums and expiration dates of your prior insurance:*

Any prior claims?*

Yes
No

Please provide the dates, amounts of the claim(s) and descriptions of what happened:*

Do you have loss runs that you can provide?*

Yes
No

Please upload your loss runs here.*

Accepted file types: pdf, jpg, gif, png, xls, xlxs, doc, docx, , Max. file size: 50 MB.

(800) 696-3023

[email protected]

Forms

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Commercial - Business Owner's Application

Customer Information

Prior Insurance / Claims

Commercial Property/Location Information

Liability Coverage Options

Additional Interests