DBA/Name of Business:
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Entity Type:
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Name(s) of owners:
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% of ownership of each:
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Year business started:
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Mailing address:
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Primary location address:
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Contact Person:
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Phone:
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Fax:
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Email:
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Website:
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Describe type of business:
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Describe your business operations:
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LIABILITY INSURANCE
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Prior insurance co.:
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Effective Date:
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Liability Limit:
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Estimated annual sales/revenue:
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Estimated annual payroll:
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Estimated subcontractor costs:
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Are there any additional insureds? (landlord, etc):
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Name of Additional Insured:
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Address:
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PROPERTY INSURANCE - additional locations send in an email
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Prior Insurance Co.:
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Effective Date:
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Location Address:
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Owner or Tenant?:
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Year Built:
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Square Footage:
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What % of building is occupied by your business:
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Construction Type:
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Number of Stories:
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Sprinklered:
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Alarmed:
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Name of Alarm Co.:
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Bldg Improvements Made?:
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Wiring:
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Roofing:
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Plumbing:
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Heating/Air:
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Completed what year:
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Describe other business types in the building:
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Need Building Insurance?:
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Building Limit:
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Business Personal Property Limit:
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Computers/Media Limit:
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Mobile Equipment Limit:
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WORKERS COMP INSURANCE
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Prior Insurance Co.:
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Effective Date:
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Number of employees:
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Estimated annual payroll:
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Estimated annual sub-contractor cost:
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CLAIMS
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Any claims in the past 5 years?:
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If so, please describe:
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ADDITIONAL COMMENTS:
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FRAUD STATEMENT
Any person
who knowingly and with intent to defraud any insurance company or another person
files an application for insurance containing any materially false information,
or conceals for the purpose of misleading information concerning any fact material
thereto, commits a fraudulent insurance act, which is a crime and subjects the person
to criminal and (NY: substantial) civil penalties. (Not applicable in CO, HI, NE,
OH, OK, OR, VT). In DC, LA, ME, TN and VA, insurance benefits may also be denied.
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(You will get a summary page to review
before submitting)
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