Prime Insurance Market - Commercial Auto Insurance Form

SECTION A –(Required)
Name of person submitting *
Name of Business or Individual *
If Business, which type? *

Sub-chapter S Corporation Joint Venture LLC Partnership Trust
Business Info
Date Business started *
FEIN# *
Website *
Physical address *
Billing Address *
Phone # *
Complete description of business operations *
Annual Revenues past 12 months and/or Projected Revenues next 12 months

Lessor or owner of location (If owner please complete Section B)

# Full time employee’s# Part time employee’s

Annual Payroll for all W2 Employees (Excluding owners)

Current Insurance company Renewal date Annual Premium$
Any claim or arising claims? (If so brief description)
Section – B- Property/Building Coverage (Optional)
How much building coverage needed or on your current policy?
Year of updates to
Roof
Electrical
Plumbing
HVAC
Business Property requested amount
# of stories
Type of building
Shopping center

Yes No
Stand-alone building

Yes No
Office building

Yes No
Space occupied (Sq ft)
Construction of building

Metal Wood Frame block brick Brick over wood frame non combustible
Age of Building
Monitored Security alarm

Yes No
SECTION C –Workers Comp (Optional)
Owners of officers to be EXCLUDED
EMPLOYEES
Annual Payroll estimates (next 12 months)
Types of Labor Performed
Employees
Sub-Contractors
Total Estimate payroll for this group
Employees
Sub-Contractors
SECTION D COMMERCIAL AUTO (Optional)
Existing business Or New Venture
Renewal date
How long with continuous coverage with no lapse
Current Premium
Current Company
How long with current
Vehicles
How many drivers?
Is the owner included in daily routine?
Any violations or accidents?
Cargo
General liability
Hired-non owned
Filings State/Fed
Signature:
Email:
Should be Empty:

SECTION A –(Required)

Section – B- Property/Building Coverage (Optional)

SECTION C –Workers Comp (Optional)

SECTION D COMMERCIAL AUTO (Optional)