Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.General Information What is the name of your business ?Who should we contact for further information?What is the contact person’s title?What is the contact person’s phone number?What is the contact person’s email address?What is the business address?NextBusiness Information What type of business do you have?How many years has your business been in operation?What is your annual revenue?How many employees do you have?What is the structure of your business?CorporationLLCPartnershipSole ProprietorshipOther (please specify)OtherNextCurrent Insurance Inform Who is your current insurance providerWhat is your current policy number(s)?What is the expiration date of your current policy?What types of coverage do you currently have ?General LiabilityProperty InsuranceWorkers' CompensationCommercial AutoProfessional LiabilityOther (please specify)OtherNextCoverage Needs What type of coverage are you looking for?General LiabilityProperty InsuranceWorkers' CompensationCommercial AutoExcess LiabilityOther (please specify)OtherWhat coverage limits do you need?What deductible preferences do you have?Do you have any special coverage requirements or requests? If so, please specifyNextCommercial General Liability Do you have any hazardous or high-risk operations?What are your annual payroll and sales (please estimate)?Are there any subcontractors used? If so, what is the annual cost of subcontractors?NextCommercial Auto Liability How many vehicles are in your fleet?123What type of vehicles are used?What are the vehicle identification numbers (VINs)? Vehicle 1 VINVehicle 2 VINVehicle 3 VINWho are the drivers, and what are their driving records? Driver 1Driver 2Driver 3NextExcess Liability What primary liability policies do you currently have?What are the limits of those policies?Do you require specific coverages under excess liability?NextWorkers Compensation What are your annual payroll and number of employees per job classification? Estimated Annual PayrollJob Classification# FT Employees address? vehicles is # PT EmployeesDo you have any safety programs or protocols in place?Have you had any workers' compensation claims in the past five years?NextProperty Information Address of premisesWhat type of property is it?OfficeRetailWarehouseManufacturingOther (please specify)OtherWhat year was the property built?What is the construction type of the property?What is the square footage of the property?What is the current market value of the property?NextAdditional Information Have you had any claims in the last 5 years? If so, please describeCan you provide a description of your operations?Is there any additional information or comments you would like to add?Submit
