Business Identity

Company Name *

Primary Contact First Name *

Last Name *

Phone *

Email *

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

Business Identity

Years of Industry Experience *

Description of Operations *

General Liability Limit Requested *

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

Square Footage Occupied

Total Floors in Building

Floor of Building

Year Building Was Built

Building Information

Construction Type

Roof Type

Fire Alarm Type

Sprinkler System Present?

Yes

Unknown

Security System

Yes

Unknown

Operational Exposures

Annual Gross Revenue *

Number of Employees

Does your business involve physical products?

Yes

Do clients visit your premises?

Yes

Do you perform any work off-premises?

Yes

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

Yes

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?

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