Forms

Commercial – Business Owner’s Application

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Commercial - Business Owner's Application

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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?*

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

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

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

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

Yes

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

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

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

Yes

Have any products been recalled, discontinued or changed?*

Yes

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

Yes

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

Yes

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

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

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

Do you rent or loan equipment to others?*

Yes

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

Are there any parking facilities owned or rented?*

Yes

Is a fee charged for parking?*

Yes

Are social events sponsored?*

Yes

Are atheltic teams sponsored?*

Yes

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

Yes

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

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

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

Yes

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

Yes

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

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

Yes

Do you lease employees to or from other employers?*

Yes

Is this a home-based business?*

Yes

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

Are day care facilities operated or controlled?*

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

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

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

Prior Insurance / Claims

Any prior insurance?*

Yes

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

Any prior claims?*

Yes

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

Do you have loss runs that you can provide?*

Yes

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 Information

Are 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 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

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

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

Is there any demolition exposure contemplated?*

Yes

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 Options

Please select a General Liability limit.*

You need to request General Liability if you're going to request Excess/Umbrella Liability.

Will you require primary and non-contributory wording?*

Please 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?*

Please 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?*

Please select an Excess/Umbrella Liability limit.*

Excess 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?*

Hired 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 Interests

Do you have a lender, landlord or other business relation that needs to be added to coverage?*

Yes

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 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.

Phone

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