Commercial Insurance Application

First Name (required):

Middle Name:

Last Name (required):

Other Named Insured:

Mailing Address:

Property Address (if different from mailing):

Telephone Number:

Email Address (required):

Website Address:

FEIN or Social Security #:

Retail %:

Wholesale %:

Importing %:

Type of Company:
 Individual Partnership Corporation Joint Venture Subchapter S Corporation Not For Profit Organization LLC

Date Business Started (mm/dd/yyyy):

# of Years in the Industry:

Current Insurance Information

Current Insurance Carrier:

Policy #:

Premium:

Expired Date (mm/dd/yyyy):

Premises Information

Building #1

Address:

Ownership:
 Owner Tenant

Nature of Business:

Year Built:

Number of Employees:

Percentage Occupied:

Square Footage:

Number of Stories:

Number of Apt Units:

Construction of the Building:
 Brick Stucco Frame Other

Burglar Alarm:
 None Local Central

Smoke Detector Alarm:
 None Local Central

Year of Update for Roof:

Year of Update for Electricity:

Year of Update for Heat:

Year of Update for Plumbing:

Limits

Building:

Contents:

Business Income:

Improvements & Betterments:

Deductible:

Employees:

#Males:

#Females:

Payroll:

Sales:

Name of Mortgagee or Landlord:

Optional Coverage

Glass Coverage:
 Yes No

Linear Feet:

Building #2

Address:

Ownership:
 Owner Tenant

Nature of Business:

Year Built:

Number of Employees:

Percentage Occupied:

Square Footage:

Number of Stories:

Number of Apt Units:

Construction of the Building:
 Brick Stucco Frame Other

Burglar Alarm:
 None Local Central

Smoke Detector Alarm:
 None Local Central

Year of Update for Roof:

Year of Update for Electricity:

Year of Update for Heat:

Year of Update for Plumbing:

Limits

Building:

Contents:

Business Income:

Improvements & Betterments:

Deductible:

Employees:

#Males:

#Females:

Payroll:

Sales:

Name of Mortgagee or Landlord:

Optional Coverage

Glass Coverage:
 Yes No

Linear Feet:

Umbrella Policy Coverage:
 Yes No 1 Million 2 Million 3 Million Other
*Please attach supplementary sheets for additional premises.

General Information

1. Is the applicant a subsidiary of another entity?
 Yes No
If yes, please state reason

2. Does the applicant have any subsidiaries?
 Yes No
If yes, please state reason

3. Is a formal safety program in operation?
 Yes No
If yes, please state reason

4. Any exposure to flammables, explosives, chemicals?
 Yes No
If yes, please state reason

5. Any catastrophe exposure?
 Yes No
If yes, please state reason

6. Any other insurance with this company or being submitted?
 Yes No
If yes, please state reason

7. Any policy or coverage declined, canceled or non-renewed during the prior 3 years?
 Yes No
If yes, please state reason

8. Any past losses or claims relation to sexual abuse or molestation allegations, discrimination or negligent hiring?
 Yes No
If yes, please state reason

9. During the last five years, has any applicant been convicted of any degree of the crime of arson?
 Yes No
If yes, please state reason

10. Any uncorrected fire code violations?
 Yes No
If yes, please state reason

11. Any bankruptcies, tax or credit liens against the applicant in the past 5 years?
 Yes No
If yes, please state reason

12. Has business been placed in a trust?
 Yes No
If yes, please state reason

Loss History

Address:

Date of Occurence (mm/dd/yyyy):

Type/Description of occurence or claim:

Date of Claim (mm/dd/yyyy):

*Note: Five year loss history required.
*Please attach supplementary sheets for additional premises.

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