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Agent*

Agent Phone*

Requested Effective Date

MM slash DD slash YYYY

Agent Fax

Legal entity of insured *

Individual

Partnership

Corporation

LLC

Year business was started*

DBA*

Named insured*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone*

Fax Phone

Federal Tax ID#

Description of Operations*

Insured's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insured location is the same as the mailing address? Please provide if different

Insured's location is the same as the mailing address? Please provide if different

Insured's Website

Is the insured operating under another entity or business?

Yes

No

Additional Insured Locations:#

Location #1 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Location #2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Location #3 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Quoting

BOP/GL/Property

Auto

WC

Umbrella

Other

Any bankruptcies in the past 7 years?

Yes

No

Any liens on business?

Yes

No

Has insured been cancelled, declined, or non-renewed by another carrier within the past year?

Yes

No

Workers Compensation

Number of Employees Full Time

Number of Employees Part Time

Payroll Total $

Experience Modification

Payroll by classification (Please provide class # and payroll )

General Liability

Receipts $

Any Manufacturing Activities

Limit of Liability $ (CSL)

OR Split Liability / $

Property Damage $

Gross Sales by Classification

Operations

Operations

Operations

Products

Products

Products

Additional Endorsements:

Commercial Auto

Hired Auto Libility

Yes

No

Non-owned Liability

Yes

No

Liability Limit

UM/UIM Limit: $

PIP: $

Physical Damage: Comp Ded. $

Collision Ded. $

Additional Endorsements:

We will need the vehicle schedule that would include serial numbers and cost new

Commercial Property

Occupancy Type:

Owner

Tenant

Lessor

Age of Construction

Number of stories

Building Square Feet

Construction:

Frame

Joisted Masonry

Non-Combustible

Masonry Non-Combustible

Modified Fire Resistive

Fire Resistive

Location Sprinklered:

Yes

No

Safe on Premises:

Yes

No

Alarms:

Yes

No

Year of Improvements:

Wiring

Plumbing

Roof

Heating

Building Limit: $

Replacement Cost: $

Actual Cost Value: $

Business Personal Limit: $

Business Income: $

Coinsurance (%)

Deductible

$250

$500

$1000

$2500

Other

Umbrella

Umbrella

Yes

No

Limit of Liability

$1M

$2M

$3M

$4M

$5M

Claims History by Line of

Additional Information

Contact Info

Name

First Last

Email

Phone

Email

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Contact Us

Rehm Insurance & Financial Services
150 St. Andrews Court, Suite 510
Mankato, Minnesota 56001
507-345-3366
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