Business Information
Business Name
*
Business Entity (eg LLC, Inc, Sole Proprietor)
*
Owners Name # 1
*
Owners Name # 2
Business Address
*
Business Phone
*
Business Email
*
Type of Business (eg Restaurant, Dentist, etc. )
*
Years in Business
*
Website
*
Last Year Gross Sale
*
How many square feet does your business occupy ?
*
Value of Personal property (eg furniture, computers, printers)
*
Does your business have an alarm system ?
*
Yes
No
Does your business have a fire sprinkler system?
*
Yes
No
Any Claims or Losses in last 5 years
*
Current Insurance Carrier?
Current Insurance Policy Renewal Date ?
Current Insurance Policy Number ?
Building Information
Do you own the building or lease at your location ?
If you own the building, what is the approx. current market value?
What year was the building built?
How many stories?
What is the square footage?
Type of Construction?
Roof Type?
Workers Comp
Total number of employees (excluding owners)?
Total Annual Payroll for employees only?
Number of full time employees?
Number of part time employees?
Any Claims or Losses in last 5 years
Commercial Auto
Vehicle #1
Number of Drivers
Year, Make & Model
Current Odometer (mileage)
Coverage requested
100/300
250/500
300/750
1,000,000 CSL
Vehicle #2
Number of Drivers
Year, Make & Model
Current Odometer (mileage)
Coverage requested
100/300
250/500
300/750
1,000,000 CSL
Notes
Referred by
Upload Documents (e.g. current insurance policy, driver’s license, registration)
Browse Files
Cancel
of
Submit
Should be Empty: