Primary contact name
*
First Name
Last Name
Phone
*
(###)
###
####
Email address
*
Complete legal business name
*
Doing business as name (if applicable)
FEIN/Tax ID #
*
Business entity type (Corp, LLC, Individual, etc.)
*
Business address or primary location
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Any other location(s) address (if applicable)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Please specifically describe the business you are engaged in
*
Give as much detail as possible
Provide full product list
*
Please be specific
Date business was established
*
MM
DD
YYYY
Are you currently insured
*
Number of W-2 employees
*
Number of 1099 contractor employees
*
Do you own more than 50% in any other business
*
If yes, please describe the other business and if you have coverage for the other business below
If you answered yes above, please provide details here
Do you work out of your home or an office
*
If you work at an office, do you own your own building
*
Square footage of office space
*
What year was the home or office building built
*
If the home or office is older than 25 years has the plumbing, HVAC and/or electrical been updated
*
If yes, please provide when and what was updated below
Please provide details to the question above here
What kind of structure is your home or office building (frame, flat roof, brick, etc.)
*
Number of stories
*
Does the building have a sprinkler
*
Does the building have an alarm system
*
Do you have sales through the internet with no customer contact (like ebay)
*
Is the business personal property all in one place
*
Any property of others that you want to insure
*
Have you had any business losses in the past 5 years
*
Does the insured have a commercial auto policy in-force
*
This question pertains to commercial auto policies only (not personal auto insurance).
How many owners, directors, employees and/or contractors regularly (3 times or more per week) use their personal autos for business
*
What is the maximum area of operation
*
Does driving involve the following
*
Please click all that apply
Please indicate the control measures in place
*
Do the insured or insured's employees regularly use hired or rental vehicles in the course of conducting business
*
Additional coverage and extensions
*
Coverages to consider - some of these come automatically, but please indicate areas of concern or areas that you want additional coverage. Please click all that apply
