Commercial Fact Finder

Agent *

Requested Effective Date

Legal entity of insured *

IndividualPartnershipCorporationLLC

DBA *

Agent Phone *

Agent Fax

Year business was started *

Named Insured *

Address *

City/State/Zip *

Federal Tax ID#

Description of Operations *

Business Phone *

Fax Phone

Insured's Website

Insured Address

Insured City/State/Zip

Insured's Address

Insured's City/State/Zip

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

Is the insured operating under another entity or business?

YesNo

Additional Insured Locations:#

Location 1 Address

Location 2 Address

Location 3 Address

Location 1 City/State/Zip

Location 2 City/State/Zip

Location 3 City/State/Zip

Quoting

BOP/GL/PropertyAutoWCUmbrellaOther

Any bankruptcies in the past 7 years?

YesNo

Any liens on business?

YesNo

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

YesNo

Number of Employees

Full Time

Part Time

Payroll Total $

Experience Modification

Payroll by classification (Please provide class # and payroll )

Receipts $

Any Manufacturing Activities

Limit of Liability $ (CSL)

OR Split Liability / $

Property Damage $

Gross Sales by Classification

Operations

Products

Additional Endorsements:

Hired Auto Libility

YesNo

Non-owned Liability

YesNo

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

Occupancy Type:

OwnerTenantLessor

Age of Construction

Number of Stories

Building Square Feet

Construction:

FrameJoisted MasonryNon-CombustileMasonry Non-CombustibleModified Fire ResistiveFire Resistive

Location Sprinklered:

YesNo

Safe on Premises:

YesNo

Alarms:

YesNo

Year of Improvements:

Wiring

Plumbing

Roof

Heating

Building Limit: $

Replacement Cost: $

Actual Cost Value: $

Business Personal Limit: $

Business Income: $

Coinsurance (%)

Deductible

$250$500$1,000$2,500Other

Other

Umbrella

YesNo

Limit of Liability

$1M$2M$3M$4M$5M

Claims History by Line of

Additional Information

Contact Name *

Contact Email *

Contact Phone *