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* indicates Required Field

General Information
Company Name:*
Entity Type:*
Contact Name:*
Phone #:* Ext:
Email Address:*
Mailing Address:*
City:* State:* Zip:*
Year Business Started:*
Federal ID #:* (Please enter Soc. Sec. # if Sole Proprietor)
Proposed Effective Date:*
Description of Retail Operations:*

Package Policy (General Liability and Property)

How many locations are you adding to this package?*  

Workers' Compensation
*** Estimated Payroll for upcoming 12 months ***

Please Note: The maximum payroll to include is:
  • $58,200 for self employed (Sole Proprietors)
  • $62,400 for Executive Officers

  • Class Code: Job Description: Average # of Employess: Annual Payroll:
    Executive Officer(s) Information
    % Ownership
    Do you have any: Waivers of Subrogation (Check if applies)
    Have you had continuous Workers' Comp coverage for the past 3 years? Yes No

    If "Yes", please answer next question below
    Name of Carrier:
    Policy Number:
    Have you had any claims in the last 3 years? Yes No
    Liability Limits Desired:
    Are the owners covered by health insurance?: Yes No

    Commercial Auto Insurance
    (Please Note: If you use your own personal auto, you do not need to provide commercial auto insurance information.)
    Limits desired:
    Do you provide deliveries? Yes No
    If "Yes" above, radius (miles):
    Vehicle Information
    VIN Number
    Cost New1
    Auto #1
    $ / $
    1 What the vehicle cost new is only required if you want full coverage (physical damage) on the auto. Even if you bought used, estimate cost new.

    2 If you only want liability coverage, mark "N/A".

    Driver Information
    Driver Name
    Date of Birth
    State Licensed
    Drivers License #
    Driver #1
    Have you had continuous coverage for the past 3 years? Yes No

    If "Yes", please answer next question below
    Name of Carrier:
    Policy Number:
    Have you had any claims in the last 3 years? Yes No

    Commercial Umbrella
    Limits requested:

    Additional Comments
    Please give any additional comments you feel appropriate for this quotation. If you have
    additional information where there was not enough fields above, please enter them here.

    Submission Info
    The applicant has read the foregoing and understands that completion of this Application does not bind the Underwriter or the Broker to provide coverage. It is agreed, however, that this Application is complete and correct to the best of applicant's knowledge and belief and that all particulars which may have a bearing upon acceptability as a Professional Liability insurance risk have been revealed. It is understood that this Application shall form the basis of the contract should the Underwriter approve coverage and should the applicant be satisfied with the Underwriters quotation.
    CHECK HERE:  I acknowledge that the information I am providing in this submission is true and accurate to the best of my knowledge.
    Your Name:
    Your Title:

    PLEASE DO NOT SUBMIT this application unless you have
    completed the General Information section at the top of this form.

    Please click on the "Submit Application" button to send your quote request.
    One of our representatives will respond to your submission as soon as possible.


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