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Name
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First
Middle
Last
Company Name (Applicant)
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Address
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Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number
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Email
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Website
Form of Business
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Sole Proprietor
Corporation
Partnership
LLC
Limited Liability Corporation
Other
If Other, please explain:
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Description of Business/Services provided:
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Employer ID # (FEIN)
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# of Years in Business
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# of Years Experience
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Annual Receipts/Revenue $:
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Annual Payroll
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Number of Owners/Officers/Partners:
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If a law firm, how many attorneys?
Total # of Full Time Employees
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Total # of Part Time Employees
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Are Subcontractors and/or Independent Contractors Used?
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Yes
No
Do you currently have property/general liability coverage in place?
(required)
Yes
No
Carrier
Expiration Date (MM/DD/YYYY)
Premium
If no current coverage, provide requested effective date of policy (MM/DD/YYYY):
Have you had any claims within the last 3 years?
(required)
Yes
No
Do you have additional locations where coverage is desired?
(required)
Yes
No
Please provide addresses for all locations where coverage is desired:
(required)
Business Personal Property Limit
(required)
Computer Property & Media Limit
(required)
Deductible:
(required)
$500
$1,000
$2,500
$5,000
Property Additional Interest (Loss Payee / Mortgagee)
(required)
Requested General Liability Coverage:
(required)
$1,000,000 per occurrence / $2,000,000 aggregate
$2,000,000 per occurrence / $4,000,000 aggregate
Does your lease require ADDITIONAL INSURED status for Landlord/Property Manager?
(required)
Yes
No
If yes, please provide name and address as it should appear on the Certificate of Insurance:
Umbrella Liability (optional coverage for an additional premium)
$1,000,000
$2,000,000
Other
Are any autos titled in the name of, owned by or leased by your business?
(required)
Yes
No
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