business owners (BOP) insurance Quote Request Form

Toll Free Phone: 1-844-840-1400

If you are searching for an affordable business owners insurance policy (BOP), we encourage you to complete the form below. We can provide some of the most comprehensive coverage at great rates.

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 *

YYYY

Are you currently insured *

Yes

Estimated gross annual commission sales revenue *

Please estimate if necessary

Number of managers, LLC members and executive officers *

Number of W-2 employees *

Total W-2 reported payroll *

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

Yes

If you answered yes above, please provide details here

Website address

http://

Do you work out of your home or an office *

Home

Office

If you work at an office, do you own your own building *

Yes

If you own your own office building, what is the replacement value to insure

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

Yes

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 *

Yes

Does the building have an alarm system *

Yes

Do you have sales through the internet with no customer contact (like ebay) *

Yes

Amount of insurance needed to cover the business personal property or inventory? *

Is the business personal property all in one place *

Yes

Any property of others that you want to insure *

Yes

Have you had any business losses in the past 5 years *

Yes

Does the insured have a commercial auto policy in-force *

This question pertains to commercial auto policies only (not personal auto insurance).

Yes

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 *

Local (< or = 50 miles)

Intermediate (51 to 200 miles)

Long distance (> 200 miles)

N/A

Does driving involve the following *

Please click all that apply

Time constraints

Routine errands

Student or youth transport

Outside sales

Other deliveries

N/A

Please indicate the control measures in place *

Employees carry Personal auto liability coverage of $100K/$300K/$50K split or $300K single limit

Drivers MVRs are on file and checked annually by insured

Age and driving experience considered in allowing use of personal vehicles

N/A

Do the insured or insured's employees regularly use hired or rental vehicles in the course of conducting business *

Yes

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

For sales professionals

Click all that apply

Property in-transit

EPLI - insurance against lawsuits arising from: wrongful termination, sexual harassment, gender discrimination, sexual discrimination, etc.

Data Breach - sensitive data loss

Commercial Auto Liability

Property Owners

Select all that apply

Preservation of property

Increased cost of construction

Pollutant clean-up

Electronic data

Newly acquired property

Valuable papers

Outdoor property/signs

Non-owner detached trailers

Please use this area to provide any additional notes or ask questions as needed

Thank you!

Fencing contractor business owners (BOP) insurance Quote Request Form

Toll Free Phone: 1-844-840-1400

If you are searching for an affordable Fencing Contractor business owners insurance policy (BOP), we encourage you to complete the form below. We can provide comprehensive coverage for Fencing Contractors at a great rate.

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 *

YYYY

Are you currently insured *

Yes

Estimated gross annual commission sales revenue *

Please estimate if necessary

Number of managers, LLC members and executive officers *

Number of W-2 employees *

Total W-2 reported payroll *

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

Yes

If you answered yes above, please provide details here

Website address

http://

Do you work out of your home or an office *

Home

Office

If you work at an office, do you own your own building *

Yes

If you own your own office building, what is the replacement value to insure

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

Yes

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 *

Yes

Does the building have an alarm system *

Yes

Do you have sales through the internet with no customer contact (like ebay) *

Yes

Amount of insurance needed to cover the business personal property or inventory? *

Is the business personal property all in one place *

Yes

Any property of others that you want to insure *

Yes

Have you had any business losses in the past 5 years *

Yes

Does the insured have a commercial auto policy in-force *

This question pertains to commercial auto policies only (not personal auto insurance).

Yes

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 *

Local (< or = 50 miles)

Intermediate (51 to 200 miles)

Long distance (> 200 miles)

N/A

Does driving involve the following *

Please click all that apply

Time constraints

Routine errands

Student or youth transport

Outside sales

Other deliveries

N/A

Please indicate the control measures in place *

Employees carry Personal auto liability coverage of $100K/$300K/$50K split or $300K single limit

Drivers MVRs are on file and checked annually by insured

Age and driving experience considered in allowing use of personal vehicles

N/A

Do the insured or insured's employees regularly use hired or rental vehicles in the course of conducting business *

Yes

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

For sales professionals

Click all that apply

Property in-transit

EPLI - insurance against lawsuits arising from: wrongful termination, sexual harassment, gender discrimination, sexual discrimination, etc.

Data Breach - sensitive data loss

Commercial Auto Liability

Property Owners

Select all that apply

Preservation of property

Increased cost of construction

Pollutant clean-up

Electronic data

Newly acquired property

Valuable papers

Outdoor property/signs

Non-owner detached trailers

Please use this area to provide any additional notes or ask questions as needed

Thank you for the submission of your Fencing Contractor business owner’s policy (BOP) quote request form. One of our representatives will contact you very soon with quotes and additional details. In the meantime, please feel free to call us at 719-630-1397 or by emailing [email protected] with any questions.

Thank you for the opportunity to be of service!

Superior Fence & Rail Franchise owners
(BOP) insurance Quote Request Form

Toll Free Phone: 1-844-840-1400

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 *

YYYY

Are you currently insured *

Yes

Estimated gross annual commission sales revenue *

Please estimate if necessary

Number of managers, LLC members and executive officers *

Number of W-2 employees *

Total W-2 reported payroll *

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

Yes

If you answered yes above, please provide details here

Website address

http://

Do you work out of your home or an office *

Home

Office

If you work at an office, do you own your own building *

Yes

If you own your own office building, what is the replacement value to insure

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

Yes

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 *

Yes

Does the building have an alarm system *

Yes

Do you have sales through the internet with no customer contact (like ebay) *

Yes

Amount of insurance needed to cover the business personal property or inventory? *

Is the business personal property all in one place *

Yes

Any property of others that you want to insure *

Yes

Have you had any business losses in the past 5 years *

Yes

Does the insured have a commercial auto policy in-force *

This question pertains to commercial auto policies only (not personal auto insurance).

Yes

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 *

Local (< or = 50 miles)

Intermediate (51 to 200 miles)

Long distance (> 200 miles)

N/A

Does driving involve the following *

Please click all that apply

Time constraints

Routine errands

Student or youth transport

Outside sales

Other deliveries

N/A

Please indicate the control measures in place *

Employees carry Personal auto liability coverage of $100K/$300K/$50K split or $300K single limit

Drivers MVRs are on file and checked annually by insured

Age and driving experience considered in allowing use of personal vehicles

N/A

Do the insured or insured's employees regularly use hired or rental vehicles in the course of conducting business *

Yes

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

For sales professionals

Click all that apply

Property in-transit

EPLI - insurance against lawsuits arising from: wrongful termination, sexual harassment, gender discrimination, sexual discrimination, etc.

Data Breach - sensitive data loss

Commercial Auto Liability

Property Owners

Select all that apply

Preservation of property

Increased cost of construction

Pollutant clean-up

Electronic data

Newly acquired property

Valuable papers

Outdoor property/signs

Non-owner detached trailers

Please use this area to provide any additional notes or ask questions as needed

Thank you for the opportunity to be of service!

Workers Compensation insurance Quote Request Form

Toll Free Phone: 1-844-840-1400

If you are searching for a workers compensation insurance policy, we encourage you to complete the form below. We will respond as quickly as possible to all submissions. Thank you!

Complete legal business name *

Doing business as name (if applicable)

Business entity type (Corp, LLC, Individual, etc.) *

Are your activities limited to sales and distribution (not a manufacturer)? *

Yes

No (we manufacture products or do other things)

FEIN # / TAX ID # *

Primary contact name *

First Name

Last Name

Phone *

(###)

###

####

Email address *

Website address

http://

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 and the nature of the products you represent *

Give as much detail as possible

Date business was established *

YYYY

Are you currently insured for workers compensation *

Yes

Gross annual sales revenue *

Please estimate if necessary

Number of W-2 employees *

Total W-2 reported payroll *

Number of 1099 contractor employees *

Are any employees leased from a PEO organization *

Yes

If you are covering employees or contractors who work off-site please specify the address of the employees that do not work at your place of business

If you answered yes above, please provide details here

What does each employee or class of employee do for the company *

Please provide details to the question above here

Estimated annual payroll for each employee above *

What state or states do you or your employees travel to *

Do you want to include owners/officers *

Yes

Estimated annual compensation for each owner/officer/director electing coverage

Please list the estimated annual compensation for each owner/officer/director electing coverage here.

Does your company qualify for experience MOD (if applicable) *

Yes

I don't know

N/A

Any losses in the past 5 years *

Yes

If you have had a WC loss (claim) in the past, do you have your loss history *

If yes, please email your loss history to [email protected]

Yes

Does your company have a safety program that you adhere to *

Yes

Please use this area to provide any additional notes or ask questions as needed

Thank you!

Directors and Officers Liability Insurance (D&O Insurance)

Directors & Officers (D&O) liability insurance covers directors and officers for claims made against them while serving on a board of directors or as an officer.

To learn more or to receive a customized quote for D&O liability insurance coverage, please complete the form below or contact us.

Name of Organization *

Address *

Only available to clubs and chapters located in the United States. Please list USA in the Country field.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address *

Nature of Operations *

Date of Incorporation

YYYY

Contact Person *

First Name

Last Name

Phone *

(###)

###

####

Coverage Questions

Proposed Effective Date *

YYYY

Directors & Officers Liability (D&O) / Employment Practices Liability Insurance

If desired, please check the box below and provide your desired D&O insurance limit

Desired D&O Insurance Limit *

ORGANIZATION INFORMATION

Total Annual Gross Revenues (from membership dues) *

(If Revenue is greater than $1,000,000, please provide a copy of the most recent CPA Audit or IRS Form 990)

Total Assets *

Is the Organization involved in any lending, credit or collection activities? *

If yes, please provide details below

Yes

Does the organization have an annual or bi-annual meeting, convention or similar gathering? *

Yes

Is the Organization currently or has it at any time over the last year been in breach or violation of any debt covenant or loan agreement or any other material contractual obligation? *

If yes, please provide details below

Yes

Has the Organization experienced within the past 2 years or does the Organization expect any of the following events within the next 2 years:

Any financial reorganization or filing for bankruptcy? *

If yes, please provide details below

Yes

Any downsizing, layoffs, reduction in force, or office closings? *

If yes, please provide details below

Yes

Does the organization maintain:

An audit committee? *

Yes

An investment committee? *

Yes

An executive compensation committee? *

Yes

Please list the following information for the current 12 months (if “None”, please indicate):

Total # of Full Time Employees *

Enter "0" if none

Total # of Annual Volunteers *

Total # of Part Time/Seasonal Employees *

Involuntary Terminations *

Resignations *

Does the Organization maintain and distribute an employee handbook? *

Yes

Does the Organization have a Human Resources Department? *

Yes

Prior Knowledge

Does anyone for whom insurance is being applied have any knowledge or information of any error, misstatement, misleading statement, act omission, neglect, breach of duty or other matter that may give rise to a claim that may fall within the scope of coverage of the proposed insurance? *

If yes, please provide details below

Yes

IT IS AGREED THAT IF SUCH KNOWLEDGE OR INFORMATION EXISTS, ANY CLAIM BASED ON, ARISING FROM, OR IN ANY WAY RELATING TO SUCH ERROR, MISSTATEMENT, MISLEADING STATEMENT, ACT, OMISSION, NEGLECT, BREACH OFDUTY OR OTHER MATTER OF WHICH THERE IS KNOWLEDGE OR INFORMATION SHALL BE EXCLUDED FROM COVERAGE UNDER THE INSURANCE BEING APPLIED FOR. *

YES, I AGREE

NO, I DO NOT AGREE

Loss History

Within the last 3 years, has the applicant, its directors, officers and/or any other proposed insured person or organization received any complaint, suit, inquiry or notice of hearing from any state or federal body, or any other party? *

If yes, please provide details below.

Yes

Has any Insurer cancelled or refused to renew any Directors and Officers, Employment Practices, Fiduciary Liability, Crime/Fidelity, or similar insurance within the past 3 years? *

If yes, please provide details below.

Yes

IT IS AGREED THAT IF ANY SUCH COMPLAINTS, SUITS, INQUIRIES OR NOTICES EXIST, ANY CLAIM BASED UPON, ARISING FROM OR IN ANY WAY RELATED TO SUCH MATTERS SHALL BE EXCLUDED FROM THE INSURANCE BEING APPLIED FOR. THE INFORMATION PROVIDED IN THIS APPLICATION IS FOR UNDERWRITING PURPOSES ONLY AND DOES NOT CONSTITUTE NOTICE TO THE COMPANY OF A CLAIM OR POTENTIAL CLAIM UNDER ANY POLICY. IF YOU INTEND TO NOTICE A CLAIM OR POTENTIAL CLAIM FOR POSSIBLE COVERAGE, PLEASE COMPLY WITH THE NOTICE OF CLAIM CONDITIONS/PROVISIONS FOUND IN YOUR POLICY, BY SENDING WRITTEN NOTICE OF SUCH TO THE ADDRESS FOR THE INSURANCE COMPANY FOUND WITHIN YOUR POLICY FORMS.

California Notice: The Insurance Carrier may charge a fee if this bond or policy is cancelled before the end of its term. The fee can range between 5% to 100% of the pro rata unearned premium. Please refer to the terms and conditions stated in the policy or bond. This notice does not apply to cancellations initiated by the Insurance Company.

FRAUD WARNING STATEMENTS ALABAMA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO RESTITUTION FINES OR CONFINEMENT IN PRISON, OR ANY COMBINATION THEREOF. ARKANSAS APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICY HOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICY HOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. DISTRICT OF COLUMBIA APPLICANTS: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT." FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. HAWAII APPLICANTS: FOR YOUR PROTECTION, HAWAII LAW REQUIRES YOU TO BE INFORMED THAT PRESENTING A FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT IS A CRIME PUNISHABLE BY FINES OR IMPRISONMENT, OR BOTH. KANSAS APPLICANTS: A " FRAUDULENT INSURANCE ACT " MEANS AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO. KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS. MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY OR WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY. OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER TO DEFRAUD AN INSURER: (1) BY SUBMITTING AN APPLICATION OR; (2) FILING A CLAIM CONTAINING A FALSE STATEMENT AS TO ANY MATERIAL FACT MAY BE VIOLATING STATE LAW. PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. PUERTO RICO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD AN INSURANCE COMPANY PRESENTS FALSE INFORMATION IN AN INSURANCE APPLICATION, OR PRESENTS, HELPS, OR CAUSES THE PRESENTATION OF A FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS OR ANY OTHER BENEFIT, OR PRESENTS MORE THAN ONE CLAIM FOR THE SAME DAMAGE OR LOSS, SHALL INCUR A FELONY AND, UPON CONVICTION, SHALL BE SANCTIONED FOR EACH VIOLATION WITH THE PENALTY OF A FINE OF NOT LESS THAN FIVE THOUSAND (5,000) DOLLARS AND NOT MORE THAN TEN THOUSAND (10,000) DOLLARS, OR A FIXED TERM OF IMPRISONMENT FOR THREE (3) YEARS, OR BOTH PENALTIES. IF AGGRAVATED CIRCUMSTANCES PREVAIL, THE FIXED ESTABLISHED IMPRISONMENT MAY BE INCREASED TO A MAXIMUM OF FIVE (5) YEARS; IF EXTENUATING CIRCUMSTANCES PREVAIL, IT MAY BE REDUCED TO A MINIMUM OF TWO (2) YEARS. RHODE ISLAND APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.” TENNESSEE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW. WASHINGTON APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS." WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION." THE UNDERSIGNED AUTHORIZED OFFICER OF THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AUTHORIZED OFFICER AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE (UNDERSIGNED) WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE INSURANCE, IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE. THE “EFFECTIVE DATE” IS THE DATE THE COVERAGE IS BOUND OR THE FIRST DAY OF THE CURRENT POLICY PERIOD, WHICHEVER IS LATER. SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED AND IT WILL BE ATTACHED TO AND BECOME A PART OF THE POLICY. ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF. THIS APPLICATION MUST BE SIGNED BY THE CHAIRMAN OF THE BOARD, CHIEF EXECUTIVE OFFICER OR THE PRESIDENT OF THE ORGANIZATION.

Electronic Signature *

Please type your name if you agree to the above terms and attest to the above answers and would like to submit your application electronically.

First Name

Last Name

Title *

Address 1 *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date *

YYYY

Thank you!

Coworking organization
General Liability & Business Owners Policy (BOP) Quote Request Form

Toll Free Phone: 1-844-840-1400

For members of Coshare and others - Please complete and submit the following form to request general liability and business owners (BOP) insurance quotes. Once submitted, a member of our Coworking insurance team will contact you to discuss your specific needs and to provide a custom quote.

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 *

YYYY

Are you currently insured *

Yes

Gross annual sales revenue *

Please estimate if necessary

Number of W-2 employees *

Total W-2 reported payroll *

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

Yes

If you answered yes above, please provide details here

Website address

http://

Do you work out of your home or an office *

Home

Office

If you work at an office, do you own your own building *

Yes

If you own your own office building, what is the replacement value to insure

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

Yes

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 *

Yes

Does the building have an alarm system *

Yes

Do you have sales through the internet with no customer contact (like ebay) *

Yes

Amount of insurance needed to cover the business personal property or inventory? *

Is the business personal property all in one place *

Yes

Any property of others that you want to insure *

Yes

Have you had any business losses in the past 5 years *

Yes

Does the insured have a commercial auto policy in-force *

This question pertains to commercial auto policies only (not personal auto insurance).

Yes

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 *

Local (< or = 50 miles)

Intermediate (51 to 200 miles)

Long distance (> 200 miles)

Does driving involve the following *

Please click all that apply

Time constraints

Routine errands

Student or youth transport

Outside sales

Other deliveries

Please indicate the control measures in place *

Employees carry Personal auto liability coverage of $100K/$300K/$50K split or $300K single limit

Drivers MVRs are on file and checked annually by insured

Age and driving experience considered in allowing use of personal vehicles

Do the insured or insured's employees regularly use hired or rental vehicles in the course of conducting business *

Yes

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

Property in-transit

EPLI - insurance against lawsuits arising from: wrongful termination, sexual harassment, gender discrimination, sexual discrimination, etc.

Data Breach - sensitive data loss

Commercial Auto Liability

Preservation of property

Increased cost of construction

Pollutant clean-up

Electronic data

Newly acquired property

Valuable papers

Outdoor property/signs

Non-owner detached trailers

Special event liability

Liquor liability

Event cancellation

No additional coverage is needed

Thank you for your Coworking insurance submission. A member of our team will be in contact shortly. If you have any questions, please feel free to call us at 1-877-303-2050 or via email at [email protected].

event cancellation insurance
application

1. APPLICANT DETAILS

Applicant *

Entity to be insured (holding the event)

Primary Contact Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address *

Phone *

(###)

###

####

Fax

(###)

###

####

Website *

http://

Type of business and/or purpose of entity *

Number of years the entity has been in existance *

What is the involvement of the applicant in the event? *

Please select the item that best describes the applicant's role in the event

Organizer

Promoter

Manager

Artist

Sponsor

Other (please provide full details below)

2. EVENT DETAILS

Full Name of the Event(s) *

Name of Venue/Hotel/Convention Center *

Address of Venue/Hotel/Convention Center *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Lease Begins (Allowing for installation and dismantling) *

YYYY

Date Lease Ends (Allowing for installation and dismantling) *

YYYY

Open Dates of Event - Beginning *

Date Event opens to public and/or participants

YYYY

Open Dates of Event - Ending *

Date Event is closed to public and/or participants

YYYY

Alternate dates if any - From

YYYY

Alternate dates if any - To

YYYY

Will the event be *

Indoors

Outdoors

Under Temporary Structures

Indoors with some outdoor elements

Are you looking to insure adverse weather for the outdoor portion of an event? *

If yes, please complete the Outdoor Event supplemental application

Yes

If you have multiple events, please provide a schedule including event name, location, dates of event, financial information, and sum (limit) to be insured. This information can be emailed to [email protected]

3. Type of event

Check one

Type of Event *

Athletic or Sporting Event

Fair or Festival

Music Event

Tradeshow/Conference/Convention

Consumer Show (Art/Antique/Car/Boat/Garden)

Other (please provide full details below)

4. Financial information

Do you want to insure Gross Revenue or Expenses? *

Select One

Gross Revenue

Expenses

Budgeted Gross Revenue

Budgeted Expenses

Budgeted Net Income (Loss)

A copy of the budget is required with the application if the budgeted gross revenue or expenses exceed $1,000,000

Does any party other than the applicant have an interest in the Gross Revenue noted above? *

If yes, provide full details below

Yes

Do you have a Ticket Refund Policy? *

If yes, provide full details below. If no, then how do you intend to handle refunds and what procedure do you have in place?

Yes

Has this event been held before? *

If no, please provide details of the applicant’s experience in organizing events

Yes

Is this event open to the public? *

Yes

Have all contractual arrangements necessary for the successful fulfillment of the Event been made and confirmed in writing? *

Yes

Have all permits, contracts, visas, licenses or the like necessary of the event to be completed successfully been obtained at the time of this application or will they be obtained in good time prior to the start of the event? *

Yes

Is the venue under construction or major renovation? *

Yes

What period has been allowed for venue preparation/stage set-up? *

Number of hours

Is coverage for non-appearance of any person required for the event? *

If yes, please complete the Non-Appearance supplemental application.

Yes

Do you wish to purchase terrorism coverage? Please make your selection below *

TRIA Coverage: The event is entitled to coverage in accordance with the US Terrorism Insurance Act (TRIA).

Limited Terrorism extended to include Threat: Such cover is limited to actual acts of terrorism within a 50 mile radius of the event venue and within 50 days prior to commencement of the event extended to include threat of terrorism confirmed in writing by local or national government authorities as posing a real risk of the event.

No coverage: No terrorism coverage required for the event.

Are you aware of any circumstances, currently existing or threatened, that may possibly result in a claim under this insurance? *

If yes, provide details. NOTE: If you become aware of any such circumstances after completing this application, and before the date insurance for the event commences, you must disclose the circumstances to the insurers immediately, as this may affect this insurance.

Yes

Have you at any time within the last 5 years had a loss, or circumstances which could have led to a loss which would have been covered by this insurance? *

If yes, provide details

Yes

Do you have: (a) Any further material facts to disclose (material facts which might influence the acceptance or assessment of the application); OR (b) Any special non-standard request for coverage which you wish underwriters to consider? Please enter any material facts or special coverage requests below: *

Please provide details or type "NO" below

PLEASE READ AND SIGN (By typing your name) BELOW:

Signing this application and declaration does not bind either the application or the underwriter to provide the insurance. In the event there is any material change in the answers to the questions herein prior to the issuance date of the policy, the application form would be considered inaccurate or incomplete. The applicant will notify the insurer in writing, and, if necessary, any outstanding quotation may be modified or withdrawn. It is agreed that this application and declaration shall be attached to and form part of any policy which may subsequently be issued. To be signed by the Insured The undersigned applicant represents that the statements set forth in this application and its attachments and other materials submitted to the insurer are true and correct. In accepting any quotation provided by result of this proposal request, the insured warrants that all information and answers provided in this application are true and correct. Should an insurance policy be written, this application and any supporting information shall be incorporated into and form the basis of the written insurance policy. The Insured so warrants: *

Yes

By typing your name below, you are hereby agreeing to the terms outlined above and providing your personal warranty that all answers and responses that have been provided are true and accurate. Please note: All quotations are subject to the receipt and acceptable review of the application and other underwriting information by the underwriter. *

First Name

Last Name

Title *

Date *

YYYY

Please note: this event cancellation insurance application is subject to full underwriting. the decision to provide a quote or not is, in part, determined by the answers you have provided in the above application. Should a policy be issued, it will include certain exclusions and limitations. it is the applicant/insured's responsibility to read and understand the terms in any policy that is issued and bound. not all insurance products are available in all states. please contact the nicholas hill group with any product questions. all insurance products are provided by licensed representatives.

Agent Signature: Ryan E. Hill

Agency: Nicholas Hill Group, Inc.

Thank you for your submission! Please note: All quotations are subject to the receipt and acceptable review of the application and other underwriting information by the underwriter.

We will work closely with the underwriter to ensure that your quotes are generated and sent to your attention as quickly as possible. In the meantime, please contact us at [email protected] or by calling 1-888-224-9054 with any questions that arise.

IF YOU NEED TO INSURE ANY PORTION OF YOUR EVENT WHICH TAKES PLACE OUTDOORS, PLEASE PROCEED TO THE OUTDOOR EVENT SUPPLEMENT FORM FOUND BELOW.

We sincerely appreciate this opportunity to be of service!

EVENT CANCELLATION INSURANCE - OUTDOOR EVENT SUPPLEMENT

Only complete this Outdoor event supplement if all, or a portion of your event takes place outdoors

Applicant *

Entity to be insured (holding the event)

Primary Contact Name *

First Name

Last Name

Full Name of the Event *

If the event has both indoor & outdoor components, what proportion of the sum insured is Indoor:

Outdoor:

Please describe the extent of adverse weather that could affect the event(s) (example: light rain, moderate rain, heavy rain, high winds, etc.) *

Is the venue or any surrounding area that is being used for the event exposed to strong wind, flood or water logging? *

If yes, please provide full detail below

Yes

Will the stage or area in which the performers work be covered by a roof and on three sides and will all electrical equipment be protected to comply with industry standards against adverse weather? *

If yes, please provide full details below

Yes

If no, please give details of what protections, if any, are in place

PLEASE READ AND SIGN BELOW: To be signed by the Insured The undersigned applicant represents that the statements set forth in this supplemental application and its attachments and other materials submitted to the insurer are true and correct. In accepting any quotation provided by result of this proposal request, the insured warrants that all information and answers provided in this supplemental application are true and correct.

The Insured so warrants: *

Yes

By typing your name below, you are hereby agreeing to the terms outlined above and providing your personal warranty that all answers and responses that have been provided are true and accurate. Please Note: All quotations are subject to the receipt and acceptable review of the application and other underwriting information by the underwriter. *

First Name

Last Name

Title *

Date *

YYYY

Email *

Thank you for submitting your Outdoor Event Supplement! This supplement, along with the previous submitted application will be forwarded to the underwriters as quickly as possible and will be used to determine whether insurance coverage can be provided. If so, we will forward the quote(s) to your attention as soon as possible. In the meantime, please contact us via email at [email protected] or by calling 1-888-224-9054.

Thanks again for the opportunity to earn your business!

Welcome to the American Alpine Club Life Insurance Program! We stand ready to assist AAC members in their search for affordable "climbing friendly" life insurance plans.

Instead of taking a "one size fits all" approach, we work closely with our various insurance company partners to create a custom policy that suits your needs. In order to do so, we need to get to know you and learn more about your current health and climbing activities. Therefore, we ask that you complete the form below.

Thank you for this opportunity to be of service!

Name *

First Name

Last Name

Email Address *

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

Gender *

Male

Female

Current Health Status *

Excellent

Good

Fair

Poor

Please share any current health concerns

Tobacco Use

Never Used

Currently Use

Quit Using

If you have quit using tobacco products, please share the date that you stopped using

Are you a current AAC member? *

Yes

How much life insurance coverage are you looking for (we can quote face amounts as low as $10,000 and as high as $10,000,000)? *

Desired length of coverage? *

10 Years

15 Years

20 Years

30 Years

Lifetime Coverage

How long have you been climbing? *

Date of your last climb? *

Total number of climbs in the past 24 months? *

Do you ever climb solo or free (without the use of climbing aids)? If yes, please provide details below *

Travel and climbing plans for the next 24 months (only list trips and climbs that are actually scheduled and/or booked)? *

Travel and climbing experience in the past 24 months (if applicable, please include the highest YDS grade/numberical difficulty rating in the last 24 months)? *

Type(s) of climbing? *

click all that apply

Rock Climbing

Artificial Climbing Walls

Bouldering

Vertical Ice Climbing

Mountaineering

Other (describe below)

Please provide details to the types of climbing you engage in *

Any climbs in the past 24 months above 13,000 feet (4,000 meters)? If yes, provide details including total number of climbs, heights attained and safety equipment used. Please also include the country/region and the name of the peak(s) and route(s) and, if applicable, include the YDS grade/numerical difficulty rating (should correspond with your answers above) *

Yes

If applicable, please provide details to the question above

Please check any additional activities you have done in the past 24 months or intend to do in the next 24 months *

please check all that apply

Sky Diving

Piloting an aircraft (any type)

Bungi-jumping

Cliff diving

Base jumping

Scuba diving

Other (describe below)

None

If applicable, please provide details to the question above

Interested in other products?

Please click all that apply

Health Insurance

Disability Insurance

Accident Medical Insurance

Long-Term Care Insurance

Medicare Supplement Insurance

Gear/Equipment Coverage

Other

Thank you for your submission. A representative will be in touch as quickly as possible. If you need to speak to us immediately, please call 1-888-600-0085.

All the best,
The Nicholas Hill Team

For More Information on Mountain Climbers Insurance.

Disability Insurance
Protecting your most valuable asset... your ability to earn a living!

If you are a USA Cycling Member and would like to receive a Disability Insurance quote, please complete the form below.

Name *

First Name

Last Name

Email Address *

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

YYYY

Occupation *

Are you a USA Cycling Member? *

Yes

Gender *

Male

Female

Current Health *

Excellent

Good

Fair

Poor

Tobacco Use *

Currently use

Never used

Completely quit

Which products are you interested in? *

Check all that apply

Long-Term Disability

Short-Term Disability

Please let us know if you would like a quote for any additional products

check all that apply

Health Insurance

Accident Medical Insurance

Long-Term Care Insurance

Equipment/Gear Coverage

Dental and/or Vision Coverage

Thank you for your submission. A representative will be in touch as quickly as possible.

All the best,
The Nicholas Hill Team

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC. PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

American Quarter Horse Association
Member Life Insurance Quote Request Form

Please complete the following form to receive your no obligation life insurance quote(s).

Name *

First Name

Last Name

Email Address *

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

YYYY

Gender *

Male

Female

Current Health Status *

Excellent

Good

Fair

Poor

Tobacco Use *

Currently use

Never used

Completely quit

Are you a current AQHA Member? *

Yes

Desired amount of life insurance coverage *

Which product are you interested in? *

10 Year Term

15 Year Term

20 Year Term

30 Year Term

Return of Premium Term Options

Permanent (lifetime) Coverage

Not Sure

Other

I am also interested in the following products

check all that apply

Disability Insurance

Health Insurance

Accident Medical Insurance

Long-Term Care Insurance

Medicare Supplement Coverage

Comments

Thank you for your submission. A representative will be in touch as quickly as possible.

All the best,
The Nicholas Hill Team

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC. PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Life Insurance Quote Request Form

Name *

First Name

Last Name

Email Address *

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

YYYY

Gender *

Male

Female

Are you a member of an association we provide insurance benefits to?

If yes, please tell us which association you are a member of below

Current Health Status *

Excellent

Good

Fair

Poor

Tobacco Use *

Currently use

Never used

Completely quit

Desired amount of life insurance coverage *

Which product are you interested in? *

10 Year Term

15 Year Term

20 Year Term

30 Year Term

Return of Premium Term Options

Permanent (lifetime) Coverage

Not Sure

Other

I am also interested in the following products

check all that apply

Disability Insurance

Health Insurance

Accident Medical Insurance

Long-Term Care Insurance

Medicare Supplement Coverage

Comments

Thank you for your submission. A representative will be in touch as quickly as possible.

All the best,
The Nicholas Hill Team

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC. PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Long-Term Care & Medicare Supplement Insurance Quote Request Form

Name *

First Name

Last Name

Email Address *

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

YYYY

Gender *

Male

Female

Are you a member of an association we provide insurance benefits to?

If yes, please tell us which association you are a member of below

Current Health Status *

Excellent

Good

Fair

Poor

Tobacco Use *

Currently use

Never used

Completely quit

I am also interested in the following products

check all that apply

Life Insurance

Health Insurance

Accident Medical Insurance

Long-Term Care Insurance

Disability Coverage

Comments

Thank you for your submission. A representative will be in touch as quickly as possible.

All the best,
The Nicholas Hill Team

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC. PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Long-Term Care Insurance Quote Request Form

Name *

First Name

Last Name

Email Address *

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

YYYY

Gender *

Male

Female

Are you a member of an association we provide insurance benefits to?

If yes, please tell us which association you are a member of below

Current Health Status *

Excellent

Good

Fair

Poor

Tobacco Use *

Currently use

Never used

Completely quit

I am also interested in the following products

check all that apply

Life Insurance

Health Insurance

Accident Medical Insurance

Disability Insurance

Medicare Supplement Coverage

Comments

Thank you for your submission. A representative will be in touch as quickly as possible.

All the best,
The Nicholas Hill Team

* insurance products are provided by licensed representatives with nicholas hill group, inc. PLANS ARE SUBJECT TO FULL UNDERWRITING and include certain exclusions and limitations. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Do I Need Disability Insurance?

There is a 25% chance a worker will need this type of insurance in his or her career. Why take the risk? With Nicholas Hill Group’s disability insurance options, which are provided by highly rated insurance company partners, you can potentially have 40 to 65% of your income covered. This type of insurance is becoming more and more cost effective at the available price points.

If you have a family, this type of insurance will make sure you can pay bills, buy groceries, make car and mortgage payments, and sometimes even continue contributing to you and your children’s future investments.

Click here for more information.

Disability Insurance Quote Request Form

Name *

First Name

Last Name

Email Address *

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

YYYY

Gender *

Male

Female

Are you a member of an association we provide insurance benefits to?

If yes, please tell us which association you are a member of below

Current Health Status *

Excellent

Good

Fair

Poor

Tobacco Use *

Currently use

Never used

Completely quit

Which product are you interested in *

Long-Term Disability

Short-Term Disability

Both

I am also interested in the following products

check all that apply

Life Insurance

Health Insurance

Accident Medical Insurance

Long-Term Care Insurance

Medicare Supplement Coverage

Comments

Thank you for your submission. A representative will be in touch as quickly as possible.

All the best,
The Nicholas Hill Team

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC. PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Dental and/or Vision Insurance Quote Request Form

Name *

First Name

Last Name

Email Address *

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

YYYY

Gender *

Male

Female

Are you a member of an association we provide insurance benefits to?

If yes, please tell us which association you are a member of below

Current Health Status *

Excellent

Good

Fair

Poor

Tobacco Use *

Currently use

Never used

Completely quit

Which product are you interested in?

Dental Insurance

Vision Insurance

Both

I am also interested in the following products

check all that apply

Life Insurance

Health Insurance

Accident Medical Insurance

Long-Term Care Insurance

Disability Coverage

Comments

Thank you for your submission. A representative will be in touch as quickly as possible.

All the best,
The Nicholas Hill Team

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC. PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Mountain Bike Club/Chapter Directors and Officers Liability Insurance (D&O Insurance)

NOTICE: THE LIABILITY COVERAGE PARTS SCHEDULED IN ITEM 5 OF THE DECLARATIONS PROVIDE CLAIMS MADE COVERAGE. EXCEPT AS OTHERWISE SPECIFIED HEREIN, COVERAGE APPLIES ONLY TO A CLAIM FIRST MADE AGAINST THE INSUREDS DURING THE POLICY PERIOD OR ANY EXTENDED REPORTING PERIOD, IF APPLICABLE AND PAYMENT OF DEFENSE COSTS REDUCE THE LIMIT OF LIABILITY. NOTICE OF A CLAIM MUST BE GIVEN TO THE INSURER AS SOON AS PRACTICABLE, AFTER A NOTICE MANAGER BECOMES AWARE OF SUCH CLAIM, BUT IN NO EVENT LATER THAN NINETY (90) CALENDAR DAYS AFTER THE TERMINATION OF THE POLICY PERIOD, OR ANY EXTENDED REPORTING PERIOD. PLEASE READ THE POLICY CAREFULLY AND DISCUSS THE COVERAGE WITH YOUR INSURANCE AGENT OR BROKER.

Name of Club or Chapter *

Address *

Only available to clubs and chapters located in the United States. Please list USA in the Country field.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address *

Nature of Operations *

Date of Incorporation

YYYY

Contact Person *

First Name

Last Name

Phone *

(###)

###

####

Coverage Questions

Proposed Effective Date *

YYYY

Directors & Officers Liability (D&O) / Employment Practices Liability Insurance

If desired, please check the box below and provide your desired D&O insurance limit

Desired D&O Insurance Limit *

ORGANIZATION INFORMATION

Total Annual Gross Revenues (from membership dues) *

(If Revenue is greater than $1,000,000, please provide a copy of the most recent CPA Audit or IRS Form 990)

Total Assets *

Is the Organization involved in any lending, credit or collection activities? *

If yes, please provide details below

Yes

Does the organization have an annual or bi-annual meeting, convention or similar gathering? *

Yes

Is the Organization currently or has it at any time over the last year been in breach or violation of any debt covenant or loan agreement or any other material contractual obligation? *

If yes, please provide details below

Yes

Has the Organization experienced within the past 2 years or does the Organization expect any of the following events within the next 2 years:

Any financial reorganization or filing for bankruptcy? *

If yes, please provide details below

Yes

Any downsizing, layoffs, reduction in force, or office closings? *

If yes, please provide details below

Yes

Does the organization maintain:

An audit committee? *

Yes

An investment committee? *

Yes

An executive compensation committee? *

Yes

Please list the following information for the current 12 months (if “None”, please indicate):

Total # of Full Time Employees *

Enter "0" if none

Total # of Annual Volunteers *

Total # of Part Time/Seasonal Employees *

Involuntary Terminations *

Resignations *

Does the Organization maintain and distribute an employee handbook? *

Yes

Does the Organization have a Human Resources Department? *

Yes

Prior Knowledge

If yes, please provide details below

Yes

YES, I AGREE

NO, I DO NOT AGREE

Loss History

If yes, please provide details below.

Yes

Has any Insurer cancelled or refused to renew any Directors and Officers, Employment Practices, Fiduciary Liability, Crime/Fidelity, or similar insurance within the past 3 years? *

If yes, please provide details below.

Yes

Electronic Signature *

Please type your name if you agree to the above terms and attest to the above answers and would like to submit your application electronically.

First Name

Last Name

Title *

Address 1 *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date *

YYYY

Thank you!

Nordic center and cross country ski organization
Directors and Officers Liability Insurance (D&O Insurance)

Name of Organization *

Address *

Only available to organizations located in the United States. Please list USA in the Country field.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address *

Nature of Operations *

Date of Incorporation

YYYY

Contact Person *

First Name

Last Name

Phone *

(###)

###

####

Coverage Questions

Proposed Effective Date *

YYYY

Directors & Officers Liability (D&O) / Employment Practices Liability Insurance

If desired, please check the box below and provide your desired D&O insurance limit

Desired D&O Insurance Limit *

ORGANIZATION INFORMATION

Total Annual Gross Revenues (from all sources) *

(If Revenue is greater than $1,000,000, please provide a copy of the most recent CPA Audit or IRS Form 990)

Total Assets *

Is the Organization involved in any lending, credit or collection activities? *

If yes, please provide details below

Yes

Does the organization have an annual or bi-annual meeting, convention or similar gathering? *

Yes

Is the Organization currently or has it at any time over the last year been in breach or violation of any debt covenant or loan agreement or any other material contractual obligation? *

If yes, please provide details below

Yes

Has the Organization experienced within the past 2 years or does the Organization expect any of the following events within the next 2 years:

Any financial reorganization or filing for bankruptcy? *

If yes, please provide details below

Yes

Any downsizing, layoffs, reduction in force, or office closings? *

If yes, please provide details below

Yes

Does the organization maintain:

An audit committee? *

Yes

An investment committee? *

Yes

An executive compensation committee? *

Yes

Please list the following information for the current 12 months (if “None”, please indicate):

Total # of Full Time Employees *

Enter "0" if none

Total # of Annual Volunteers *

Total # of Part Time/Seasonal Employees *

Involuntary Terminations *

Resignations *

Does the Organization maintain and distribute an employee handbook? *

Yes

Does the Organization have a Human Resources Department? *

Yes

Prior Knowledge

If yes, please provide details below

Yes

YES, I AGREE

NO, I DO NOT AGREE

Loss History

If yes, please provide details below.

Yes

Has any Insurer cancelled or refused to renew any Directors and Officers, Employment Practices, Fiduciary Liability, Crime/Fidelity, or similar insurance within the past 3 years? *

If yes, please provide details below.

Yes

Electronic Signature *

Please type your name if you agree to the above terms and attest to the above answers and would like to submit your application electronically.

First Name

Last Name

Title *

Address 1 *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date *

YYYY

Thank you!

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Disability InsuranceProtecting your most valuable asset... your ability to earn a living!

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC. PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

American Quarter Horse AssociationMember Life Insurance Quote Request Form

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC. PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Life Insurance Quote Request Form

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC. PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Long-Term Care & Medicare Supplement Insurance Quote Request Form

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC. PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Long-Term Care Insurance Quote Request Form

* insurance products are provided by licensed representatives with nicholas hill group, inc. PLANS ARE SUBJECT TO FULL UNDERWRITING and include certain exclusions and limitations. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Do I Need Disability Insurance?

Disability Insurance Quote Request Form

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC. PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Dental and/or Vision Insurance Quote Request Form

* INSURANCE PRODUCTS ARE PROVIDED BY LICENSED REPRESENTATIVES WITH NICHOLAS HILL GROUP, INC. PLANS ARE SUBJECT TO FULL UNDERWRITING AND INCLUDE CERTAIN EXCLUSIONS AND LIMITATIONS. NOT ALL PLANS ARE AVAILABLE IN ALL STATES. PLEASE CONTACT US TO LEARN IF PLANS ARE AVAILABLE IN YOUR AREA.

Mountain Bike Club/Chapter Directors and Officers Liability Insurance (D&O Insurance)

Nordic center and cross country ski organization Directors and Officers Liability Insurance (D&O Insurance)

Superior Fence & Rail Franchise owners
(BOP) insurance Quote Request Form

Coworking organization
General Liability & Business Owners Policy (BOP) Quote Request Form

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application

Disability Insurance
Protecting your most valuable asset... your ability to earn a living!

American Quarter Horse Association
Member Life Insurance Quote Request Form

Nordic center and cross country ski organization
Directors and Officers Liability Insurance (D&O Insurance)