Business Identity

Company Name/ Property Owner *

Primary Contact First Name *

Last Name *

Phone *

Email *

Date Of Birth

By checking this box, I consent to receive transactional messages related to my insurance account.

Business Identity

Entity Type *

Website

Business Start Date / Year Founded *

FEIN / EIN

NAICS Code

Business Identity

Years of Industry Experience *

Number of Locations

Description of Operations *

Effective Start Date *

Location & Premises Details

Is this your primary business location? *

Yes

Type of Occupancy *

Location Address *

Address Line 2

City *

State *

Postal Code

Mailing Address

Same As Location Address

Mailing Address

Mailing Address Line 2

City

State

Postal Code

Building Information

Squarefootage of Entire Premisis

Total Floors in Building

Year Building Was Built

Percent of building you occupy %

Floor of Building you occupy (if applicable)

Building Information

Construction Type

Roof Type

Fire Alarm Type

Sprinkler System Present?

Yes

Unknown

Security System

Yes

Unknown

Building Information

Electrical update year

Plumbing update year

HVAC update year

Roof update year *

Building Coverage / Valuation

Is the building mixed-use?

Yes

Replacement Cost Estimate for Building / “Building Limit”

General Liability Limit Requested *

Valuation Method

Tenant Improvements & Betterments (TIB) amount

Operational Exposures

Annual Gross Revenue *

Number of Employees

Does your business involve physical products?

Yes

Usually "No" for owners who occuoupy 0% of the building

Do clients visit your premises?

Yes

Usually "No" for owners who occuoupy 0% of the building

Do you perform any work off-premises?

Yes

Usually "No" for owners who occuoupy 0% of the building

Do you have any manufacturing, shipping, warehousing, or installation operations?

Yes

Usually "No" for owners who occuoupy 0% of the building

Business Personal Property

Do you want coverage for your business personal property (equipment, furniture, computers)?

Yes

Estimated replacement cost of all property in the unit? (Dropdown)

Prior Insurance and Loss History

Do you currently carry General Liability insurance?

Yes

Current Carrier

Expiration Date

Have you had any cancellations/non-renewals?

Yes

Any claims or losses in the past 5 years?

Additional Interests

Property Manager Name

Additional Certificate Holder / Named Insured

Mortgagee Name

Mortgagee Address

Loan Number

Supporting Documents

Possible Files to Upload

• Lease agreement (PDF)

• Prior insurance policy (PDF)

• Loss runs (PDF)

• Photos of interior (optional)

• Business Description(optional)

Supporting Documents

Additional Notes