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Businessowners Policy Quote
1
Applicant Info
2
Premises Info
3
Nature of Business Info
4
General Info
5
Prior Carrier Info
6
Coverage Info
First Name
*
Last Name
*
Phone Number
*
Personal Number
Email Address
*
Mailing Address
*
Website Address
Legal Entity
*
Corporation
Individual
Joint Venture
LLC
Non-Profit Organization
Partnership
Subchapter(s) Corporation
Trust
Other
Number of Members and Managers:
Please Specify
If you know
GL Code (Optional)
SIC (Optional)
NAICS (Optional)
FEIN (Optional)
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Next
1
Applicant Info
2
Premises Info
3
Nature of Business Info
4
General Info
5
Prior Carrier Info
6
Coverage Info
Business Address:
*
Tell me about the building:
Number of Stories
*
Are you the:
Owner
Tenant
How big is the building:
The percentage of the occupied building
Square footage of your premises
Year Built
Is your operation habitational? (Habitational Only: Apartments, Condos, Hotels, and Motels)
*
No
Yes
Number of Units
*
Number of Swimming Pool(s):
*
Select all that apply
Approved Fence (Auto Lock)
Limited Access
Diving Board
Slide
Above Ground
In-Ground
LifeGuard
Has the building been renovated?
No
Yes
Electrical
Percentage of Renovation
Year Renovated
Plumbing
Percentage of Renovation
Year Renovated
Heating
Percentage of Renovation
Year Renovated
Roof
Percentage of Renovation
Year Renovated
Construction Type
---
Frame Stucco
Joisted Masonry (1 or 2 stories Concrete Block with Wood Frame)
Masonry (Brick/ Stone)
Fire Resistive (Concrete with Multiple Stories)
Other
Please Specify:
Type of Alarm
---
Local Burglary
Local Burglary and Fire
Central Burglary
Central Burglary and Fire
None
Does your building have a Fire Sprinkler?
No
Yes
Please choose the percentage of the building protected by fire sprinkler:
10%
30%
50%
70%
100%
Any Area Leased to Others?
No
Yes
Square footage leased to other?
Add information About the Area(s) Leased to Others if needed:
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Next
1
Applicant Info
2
Premises Info
3
Nature of Business Info
4
General Info
5
Prior Carrier Info
6
Coverage Info
Select your Primary Business Category below:
*
---
Apartment Building
Building Owner other than Habitational (Lessor’s Risk)
Condominium Association (HOA)
Hotel/Motel
Contractor
Institutional
Manufacturing
Office
Restaurant
Retail
Service
Wholesale
Other
Please Specify
Business Type:
*
---
Actuary
Agriculture/Forestry/Fishing
Air Traffic Controller Airport
Analyst
Architect
Art/Design/Media
Banking/Finance/Real Estate
Business/Sales/Office
Cartographer Comptroller
Certified Public Accountant
Clinical Data Coordinator
Conservationist
Construction/Energy Trades
Controller
Curator
Drafter
Economist
Education/Library
Engineer/Architect/Science/Math
Epidemiologist
Executive/Director
Financial Analyst/Auditor
Firefighter
Geographer
Government/Military
Graphic Designer
Historian
Homemaker
Identification Badge/ Business Card Accountant
Industrial Hygienist Inspector
Information Technology
Insurance
Interpreter
Laboratory Assistant
Legal/Law Enforcement/Security
Maintenance/Repair/Housekeeping
Management Ambassador
Manager- Project
Manager- R&D
Manufacturing/Production
Medical/Social Services/Religion
Medical Director
Paramedic/ EMT Group
Pilot
Planner
Postmaster
Range Ecologist
Registrar
Research Program Director
Researcher
Restaurant/Hotel Services
Sanitarian
School Teacher
Sociologist
Sports/Recreation
State Examiner
Student
Surveyor/Mapmaker
Tax Examiner
Technical Staff Manager
Technician
Therapist
Toxicologist
Training Specialist
Translator
Travel/Transportation/Warehousing
Treasurer
Treasury Agent
Other
Please Specify
Number of Full Time Employees
*
Number of Part Time Employees
*
Annual Sales
*
Annual Payroll
*
Date Business Started
Installation, Service, OR Repair Work Percentage:
Describe Your Business
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Next
1
Applicant Info
2
Premises Info
3
Nature of Business Info
4
General
5
Prior Carrier Info
6
Coverage Info
Do you have any subsidiaries?
Yes
No
Subsidiary Company Name:
Percentage Owned:
Relationship Description:
Is a formal safety program in operation?
Yes
No
Select all that apply:
Safety Manual
Safety Position
Monthly Meetings
OSHA
Any exposure to flammables, explosives, and chemicals?
Yes
No
Any policy or coverage declined, canceled, or non-renewed during the last three years for any premises or operations?
Yes
No
Select that apply:
Non-Payment
Non-Renewal
Agent No Longer Represents Carrier
Underwriting
Condition Corrected
Describe:
Any past losses or claims relating to sexual abuse or molestation allegations, discrimination, or negligent hiring?
Yes
No
During the last five years, has any applicant ever been indicted for OR convicted of any degree of the crime of fraud, bribery, arson, or any other arson-related crime in connection with this or any other property?
Yes
No
Have you had a foreclosure, repossession, bankruptcy, or filed for bankruptcy during the last five years?
Yes
No
Occur Date:
Resolve Date:
Explanation:
Has business been placed in a trust?
Yes
No
Name of Trust:
Any foreign operations, foreign products disturbed in the USA, or US Products Sold/Distributed in foreign countries?
Yes
No
Do you have other business ventures for which coverage is not requested?
Yes
No
Do you own/lease/operate any drones?
Yes
No
Please describe:
Do you hire others to operate drones?
Yes
No
Please describe:
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Next
1
Applicant Info
2
Premises Info
3
Nature of Business Info
4
General Info
5
Prior Carrier Info
6
Coverage Info
Number of years you have been insured
0
1
2
3+
Name of Prior Carrier
*
---
Travelers
Hartford
Farmers
State Farm
All State
Chubb Corp.
CNA
Fireman’s Fund
Gaurd
AIG
CIG
Allied/Nationwide Insurance
ACE
Lloyds
Other
Please Specify
*
Have you had any losses in the last three years?
Yes
No
Loss #1
Date of Loss
Type of Loss
---
Fire
Liability
Water
Vandalism
Theft
Other
Please specify
Amount Paid
Subrogation
---
Yes
No
Claim Open
---
Yes
No
Add another loss history
Loss #2
Date of Loss
Type of Loss
---
Fire
Liability
Water
Vandalism
Theft
Other
Please specify
Amount Paid
Subrogation
---
Yes
No
Claim Open
---
Yes
No
Add another loss history
Loss #3
Date of Loss
Type of Loss
---
Fire
Liability
Water
Vandalism
Theft
Other
Please specify
Amount Paid
Subrogation
---
Yes
No
Claim Open
---
Yes
No
Back
Next
1
Applicant Info
2
Premises Info
3
Nature of Business Info
4
General Info
5
Prior Carrier Info
6
Coverage Info
Property Coverage
Building Limit (Sq ft.*Cost per Sq ft.)
Deductible
---
$500
$1000
$2500
$5000
$10000
Other
Please Specify
Business Personal Property:
Annual Loss of Income:
Personal Property of Others (if any):
Earthquake
Yes
No
Flood
Yes
No
Equipment Breakdown
Yes
No
Building Ordinance
Yes
No
Building Ordinance
---
10%
20%
50%
100%
Liability Coverage
Occurrence/Aggregate
---
$1 million / $2 million
$2 million / $4 million
Product Liability (Same as Aggregate Limit)
---
$1 million
$2 million
$4 million
Liquor Liability (If Applicable)
Yes
No
Annual Liquor Sales:
*
Classification:
*
---
Beer and Wine
Full
Hired/Non-Owned Auto
Yes
No
Garage Keepers (Applicable for Auto Related Businesses)
Additional Policies
Workers’ Compensation
Yes
No
Professional Liability / E&O
Yes
No
Employment Practice Liability (EPLI)
Yes
No
Employee Benefits Liability
Yes
No
Deductible Per Claim:
Number of Employees Covered by Employee Benefits Plan
Retroactive Date
Directors & Officers Liability
Yes
No
Commercial Umbrella
Yes
No
Amount
---
$1 million
$2 million
$5 million
Other
Please specify
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