* = Required Information
Business Information
Legal Business Name
*
DBA (if any)
Owner's Name
Contact Person
*
Business Address
Mailing Address (if different)
Phone Number
*
Email Address
*
Website
Business Details
Type of Business / Industry
FEIN / Tax ID
Entity Type
Sole Proprietorship
Partnership
LLC
Corporation (C-Corp / S-Corp)
Non-Profit
Other
If Other, specify
Number of Business Locations
Is the Business Home-Based?
Yes
No
Years in Business
Number of Employees
Annual Gross Revenue
Business Description
Coverage Requested
General Liability
Commercial Property
Workers Compensation
Commercial Auto
Professional Liability (E&O)
Cyber Liability
Business Owners Policy (BOP)
Umbrella / Excess Liability
Other
If Other, specify
General Liability Information
Annual Payroll
Annual Subcontractor Costs
Annual Gross Sales
Prior Claims?
Yes
No
If yes, explain
Property Coverage (if applicable)
Location Address
Building Owned or Leased?
Owned
Leased
Building Value
Year Built
Total Square Footage
Contents / Equipment Value
Upgrades / Renovations
Additional Property Details
Prior Property Losses?
Yes
No
If yes, explain
Workers Compensation
Total Employees
Employee Job Duties
Annual Payroll by Class Code
Prior WC Claims?
Yes
No
If yes, explain
Commercial Auto
Number of Vehicles
Prior Auto Claims?
Yes
No
Vehicle List (Year / Make / Model / VIN)
Drivers (Name & License #)
If yes, explain
Professional Liability (E&O)
Professional Services Provided
Prior E&O Claims?
Yes
No
If yes, explain
Attachments Provided
Prior Declarations Pages
Loss Runs
Photos / Inventory Lists
Other Documents
Other Documents (specify)
Additional Notes / Special Requests
Client Signature
I certify that the information provided is accurate to the best of my knowledge.
Signature (type full name)
Date
Submit