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APPLICATIONS

Contact me for a Quote

Online Application

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Business Owner Policy

Please fill out the form below. You may also fill out our short form by clicking here.

General Information

How did you hear about us? *

Named Insured:

Contractor's License #:

Owner's Name:

Contact's Name:

Phone: *

Fax:

Cell:

Email Address: *

Preferred method of contact: *
Phone

Fax

Mail

Address Information

Mailing Address
Street: *
City: *
State: *
Zip: *

Premise Address
Street:
City:
State:
Zip:

Business Entity: *

Sole Proprietorship

Partnership

Corporation

LLC

Other:
If Other:

Describe the operations at this location:

Do you own this building? Yes No

If owner is an occupant, indicate the % of occupancy:

Are you leasing it? Yes No

Any portion of the building vacant? Yes No

Do you sell or manufacture any products under your own label? Yes No

Does the applicant do any direct importing? Yes No

Are there any rental operations? Yes No

Is there any pick-up or delivery service? Yes No

Describe all the unusual operations or business practices not customary to this type of business:

Years of Experience:

Years in Business:

How long has the applicant been at this location?

Is any portion of the applicant's premises subleased? Yes No

Describe:

Neighbor/Business on the left:
Neighbor/Business on the right:
Neighbor/Business to the rear:

Number of owners, partners, officers, members:

Number of owners active in the business:

Number of Full-time employees:

Number of Part-time employees:

Annual Employee Payroll:

Subcontractor costs:

Employee Benefit Liability Coverage (EBL)? Yes No

Employee Practices Liability Insurance (EPLI)? Yes No

Please list approximate annual sales by category

Annual Gross Receipts:
Food Sales:
Gas Sales:
Alcohol Sales:
Other:
If Other, please describe:

Location Information

Construction Type:		Frame/Stucco Masonry Other If Other:
Total Area (In Square Feet):				Number of Stories:

Number of parking spaces, or square footage of parking area that you are responsible for:

Is this location on a pier, dock, or waterfront? Yes No

Electrical System:		Fuses Circuit Breaks Other If Other:
Fire protection equipment:		Fire Extinguishers Sprinklers Smoke Detectors Other If Other:
Percentage of Building that has sprinklers:

Fire Alarm:		Local (Loud noise only) Central Station (Connected to FD) None
Burglar Alarm:		Local (Loud noise only) Central Station (Connected to PD) None
Theft Coverage (must have alarm):		Yes No

Is this the predominant location/building?: Yes No

If Yes to above, please describe:

Will the business be closed for remodeling or building construction work during the policy period? Yes No

If Yes to above, please describe:

Has the applicant had a fire loss at this location, or other property/business locations within the last 20 years? Yes No

If Yes to above, please describe:

Building, Personal Property, and Additional Coverage Information

If the building is to be covered, please provide the following:

Current Value:			Year building was built:
Year plumbing was last updated:			Year electrical was last updated:
Year heating was last updated:			Year roofing was last updated:

Business Personal Property Value:

Select Deductable: $250 $500 $1,000 Other
If Other

Select Liability Limit: $300,000 $500,000 $1,000,000 $2,000,000 Other
If Other:

Hired auto/non-owned auto coverage? Yes No

Other coverages required:

Current insurance company (provide carrier name, policy number, and policy effective dates):

Any losses or claims in the last five years:
Yes No

If Yes to above, please describe:

Comments

Any additional information, comments or concerns?

If yes, provide details:

Legal Terms

You MUST agree to our terms and conditions to submit this request by doing both of the following:

Print your Initials: *
Print Full Name: *
I/we the undersigned hereby declare that the above statements are true and correct. This is not an application, it is only a preliminary info sheet for a quote. Additional information may be required.

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Business Owner Policy