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Business Owners Policy Insurance Estimate
Name
(required)
First
Middle
Last
Company Name (Applicant)
(required)
Address
(required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number
(required)
Email
(required)
Website
Form of Business
(required)
Sole Proprietor
Corporation
Partnership
LLC
Limited Liability Corporation
Other
If Other, please explain:
(required)
Description of Business/Services provided:
(required)
Employer ID # (FEIN)
(required)
# of Years in Business
(required)
# of Years Experience
(required)
Annual Receipts/Revenue $:
(required)
Annual Payroll
(required)
Number of Owners/Officers/Partners:
(required)
If a law firm, how many attorneys?
Total # of Full Time Employees
(required)
Total # of Part Time Employees
(required)
Are Subcontractors and/or Independent Contractors Used?
(required)
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
Name
This field is for validation purposes and should be left unchanged.
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