Commercial Application - Rehm Insurance & Financial Services

REQUEST A QUOTE

FILE A CLAIM

Agent*

Agent Phone*

Requested Effective Date

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

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

Any bankruptcies in the past 7 years?

Yes

Any liens on business?

Yes

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

Yes

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

Products

Additional Endorsements:

Commercial Auto

Hired Auto Libility

Yes

Non-owned Liability

Yes

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

Safe on Premises:

Yes

Alarms:

Yes

Year of Improvements:

Wiring

Plumbing

Roof

Heating

Building Limit: $

Replacement Cost: $

Actual Cost Value: $

Business Personal Limit: $

Business Income: $

Coinsurance (%)

Deductible

Umbrella

Yes

Limit of Liability

Claims History by Line of

Additional Information

Contact Info

Name

First Last

Phone

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