| Name |
|
| Contact Information |
|
| Address |
|
| Legal Name of Company |
|
| Doing Business As |
|
| Date you need coverage to begin |
|
| Mailing Address |
|
| City |
|
| State |
|
| Zip Code |
|
| Legal Structure of the Company - Inc, LLC, Sole Proprietorship LLP, Other |
|
| Years in Business |
|
| Owner’s name |
|
| Phone |
|
| Fax |
|
| Email |
|
| Federal Tax ID# |
|
| Nature of your Operation |
|
| Current Insurance Carrier |
|
| Current Year Policy Number |
|
| Current Year Policy Effective Date |
|
| Current Year Premium |
|
| Has the insurance coverage ever been cancelled or not renewed? (Y or N) |
|
| Any claims paid in the last three years (Y or N) |
|
| - If yes, please list any losses in the last three years |
|
| Location #1 - Address, City, State, Zip |
|
| Location 2 - Address, City, State, Zip |
|
| Location 3 - Address, City, State, Zip |
|
| PROPERTY INFORMATION |
|
| Loc#1 - Building Limit (Replacement Cost) |
|
| Loc#1 - Year Built |
|
| Loc#1 - Square Feet |
|
| Loc#1 - Construction Type |
|
| Loc#1 - Updates & Year of Update |
|
| Loc#1 - Contents Limit (Replacement) |
|
| Loc#1 - Employee Tool Limit |
|
| Loc#1 - List Security Alarm, Cameras, or other |
|
| Loc#2 - Building Limit (Replacement Cost) |
|
| Loc#2 - Year Built |
|
| Loc#2 - Square Feet |
|
| Loc#2 - Construction Type |
|
| Loc#2 - Updates & Year of Update |
|
| Loc#2 - Contents Limit (Replacement) |
|
| Loc#2 - Employee Tool Limit |
|
| Loc#2 - List Security Alarm, Cameras, or other |
|
| Loc#3 - Building Limit (Replacement Cost) |
|
| Loc#3 - Year Built |
|
| Loc#3 - Square Feet |
|
| Loc#3 - Construction Type |
|
| Loc#3 - Updates & Year of Update |
|
| Loc#3 - Contents Limit (Replacement) |
|
| Loc#3 - Employee Tool Limit |
|
| Loc#3 - Security |
|
| Percentage of Sales Retail Sales |
|
| Percentage of Wholesale Sales |
|
| Other |
|
| Explain Other |
|
| Total Annual Gross Sales |
|
| Total Annual Gross Payroll |
|
| General Liability limit requested (per occurrence) ($500k or $1m) |
|
| Would you like coverage for Employment Practices Liability (Y or N) |
|
| Would you like coverage for Cyber Liability Insurance (Y or N) |
|
| Type of business operation? |
|
| Numer of Employees: |
|