PREPARE
FOR THE FUTURE
We believe when something happens, you need a trusted professional, not a 1-800 number.
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?
Any liens on business?
Has insured been cancelled, declined, or non-renewed by another carrier within the past year?
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 $
Operations
Products
Additional Endorsements:
Hired Auto Libility
Non-owned Liability
Liability Limit
UM/UIM Limit: $
PIP: $
Physical Damage: Comp Ded. $
Collision Ded. $
Occupancy Type:
OwnerTenantLessor
Age of Construction
Number of Stories
Building Square Feet
Construction:
FrameJoisted MasonryNon-CombustileMasonry Non-CombustibleModified Fire ResistiveFire Resistive
Location Sprinklered:
Safe on Premises:
Alarms:
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
Limit of Liability
$1M$2M$3M$4M$5M
Claims History by Line of
Additional Information
Contact Name *
Contact Email *
Contact Phone *
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COMMERCIAL INSURANCE
The right coverage lets you rest assured, so you can focus on managing and growing your business and career.
PERSONAL INSURANCE
Keep those close to you healthy, safe and secure.
LIFE INSURANCE
Get peace of mind knowing your loved ones are protected.