Commercial Insurance – Business Owner’s ApplicationEmet Digital2019-01-02T12:24:21-08:00 Get started by filling out this form and someone from our team will contact you shortly! Commercial - Business Owner's Application Customer InformationWhat 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?*Choose OneCorporationIndividual or DBAL.L.C.Non-ProfitPartnershipMailing 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 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?* MM slash DD slash YYYY 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 / ClaimsAny 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. Commercial Property/Location InformationAre you looking for Commercial Property AND Liability coverage? (PLEASE NOTE: Even if you don't want commercial property coverage, we will still need to gather information about the location in order to provide a quote for the Liability coverage you need/want)* Yes - please quote me for both No - please only quote me for commercial property coverage No - please only quote me for Liability coverage Please provide the physical address of the location to be afforded coverage by the policy:* 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 Do you:* Rent this location from someone else Own this location and use it to execute your business operations Own this location and lease it out to other businesses Own this locaiton and lease it out as lodging for individuals Own this location, lease it to others and have your own offices/operations at the location Please advise the Annual Rental Income you will generate from this property:*Do you have a rent roll you can supply?* Yes - I can upload one to this application No - but I can manually input the tenant information Please upload your rent roll*Max. file size: 50 MB.Please advise a list of the commercial tenants in the building, the amount of square feet they occupy, and their monthly rent; if there are any vacant units, please identify those as well:*How many square feet of space does your business occupy at the location?*How many stories does the building have?*Please enter a number from 1 to 50.Is the building sprinklered?* Yes - sprinklers are throughout the building Yes - but only in certain areas No What is the replacement value of the business personal property at this location?*Business personal property is the equipment you own that aids in the execution of your business operations. e.g. computers, furniture, office equipment, etc.Do you ever have the property of others in your care, custody or control?* Yes - I rent or lease equipment from time to time Yes - Our operations necessitate that we keep our clients' property overnight at times No What kind of equipment/property of others will you have in your care, custody and control?* What is the maximum value of the equipment/property of others that will be in your care, custody and control at one time?*What is the replacement value of the building?*What is the latest year that the HVAC system has been updated in the building?*Please enter a number from 1 to 2050.What is the latest year that the PLUMBING has been updated in the building?*Please enter a number from 1 to 2050.What is the latest year that the ELECTRICAL has been updated in the building?*Please enter a number from 1 to 2050.What is the latest year that the ROOF has been updated?*Please enter a number from 1 to 2050.Does the building have an alarm system?* Yes - Central Station Alarm - Fire & Burglary Yes - Central Station Alarm - Fire Yes - Central Station Alarm - Burglary Yes - Local Alarm - Fire & Burglary Yes - Local Alarm - Fire Yes - Local Alarm - Burglary No Alarm System Do you plan to make any structural changes?* Yes No Is there any demolition exposure contemplated?* Yes No Please confirm your understanding that if multiple locations will need to be afforded coverage by this policy, we will need to coordinate via email to obtain each location's details so we can offer a representative quote: Confirmed - I DO have multiple properties that will need coverage. I will coordinate with you via email. Confirmed - but I only need coverage for the one location I've listed here on the appication. Confirmed - but I don't need commercial property coverage. Liability Coverage OptionsPlease select a General Liability limit.*Exclude - Property Coverage Only$1,000,000\$1,000,000$1,000,000\$2,000,000You need to request General Liability if you're going to request Excess/Umbrella Liability.Will you require primary and non-contributory wording?*YesNoPlease advise the name and address of the specific entity who will require the primary coverage; or indicate that you would like it afforded on a blanket basis as required by written agreement/contract:* Will you require a waiver of subrogation?*YesNoPlease advise the name and address of the specific entity who will require the waiver of subrogation; or indicate that you would like it afforded on a blanket basis as required by written agreement/contract:* Will you require blanket additional insureds as required by written contract?*YesNoPlease select an Excess/Umbrella Liability limit.*Exclude$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000$6,000,000$7,000,000$8,000,000$9,000,000$10,000,000Excess or Umbrella liability provides ADDITIONAL coverage over your existing lines of liability. It DOES NOT provide blanket coverage for any and every thing.Will you require hired & non-owned Auto Liability?*YesNoHired and Non-Owned Auto Liability affords liability coverage for vehicles that your business rents or borrows (by "borrows", we mean having employees or 1099 workers use their own vehicles to execute tasks for the business).Additional InterestsDo you have a lender, landlord or other business relation that needs to be added to coverage?* Yes No Do you have (check all that may apply):* A document showing insurance requirements I'll need to meet/exceed The name and address of my landlord The name, address and loan number for my lender The name and address of some other business relation that needs to be added to coverage Please advise your loan number*The Lender's Name (as they would like it reflected on the Evidence of Insurance)* Please advise your lender's address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Please advise your landlord's name and address:* Please advise the business relationship between you/your company and the entity/individual who wants to be added to coverage: Please advise the first and last name of the individual OR the Name of the Company that would like to be added to coverage:* Please advise the individual or entity's 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 Please upload a copy of any insurance requirements you may have been provided by landlords or lenders.*Max. file size: 50 MB.If you provide documentation as to what the property owner or bank requires we can make sure that we quote you accurately for what you need to satisfy those requirements.EmailThis field is for validation purposes and should be left unchanged.