NEWS Insurance Services Inc.

Applicable to Wholesale and Manufacturing only

Products

Annual Gross Sales

# of Units

Time in Market

Epected Life

Intended Use

Principle Components

Commercial Application Form

1501 Westcliff Dr. Suite 301
Newport Beach, CA. 92660
Tel: 877-700- NEWS
Fax: 949-554-0250
Email: Info@newsinsurance.com
Web: www.newsinsurance.com

PERSONAL INFORMATION

Quote Date :
First Name :
Last Name :
Mailing Address:
City :	State : Zip Code :
Home No. :
Cell No. :
Businness No. : *	Ext.
E-Mail. :
Current Policy Expiration Date :
Social Security No. :
City :	State : Zip Code :
Choose from the Following :

PREMISES INFORMATION

Location :
City :	State : Zip Code :
Interest :
Nature of Businness/Description of Operations by Premises :

STATUS OF TRANSACTION

Proposed EFF Date :
Proposed EXP Date :

NATURE OF BUSINESS

Description of Operation:
If Other please specify :
DBA :

GENERAL INFORMATION

Please choose Yes or No for the following:

Is the applicant a subsidiary of another entity? :

Does the applicant have any subsidiaries? :

Is a formal safety program in operation? :

Any exposure to flamables, explosives, chemicals? :

Any catastrophe exposure? :

Any other insurance with this company or being submitted? :

Any policy or coverage declined, cancelled or non-renewed during the prior 3 years? :

Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring? :

During the last 5 years (ten in RI), has any applicant been convicted of any degree of the crime or arson? :

Any bankruptcies, tax or credit liens against the applicant in the past 5 years? :

Has business been placed in a trust?

Additional Comments :

PRIOR COVERAGE

COMMERCIAL GENERAL LIABILITY

Carrier :
Policy Number :
Proposed EFF Date :
Proposed EXP Date :

PROPERTY

Carrier :
Policy Number :
Proposed EFF Date :
Proposed EXP Date :

LOSS HISTORY

Enter all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the prior 5 years.						Click Here if None
Date of Occurrence	Line	Type/Description of Occurrence or Claim	Date of Claim	Amount Paid	Amount Reserved	Claim Status

COVERAGES

General Liability Limit :

SCHEDULE OF HAZARDS

Annual Sales	Sq.Footage	# of Units	Payroll	# or Emplyees

PRODUCTS

PROPERTY SECTION

PREMISES INFO

Premises #:

Building #:

Street Addres:

Building Description:

Subject of Insurance	Amount	Deductible
Building
Business
Personal Property
Loss of Income