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submitting your information by pressing the "Submit" button at the bottom of this form.
* 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?*
LOCATION #1
Physical Address:
City:
State:
Zip:
County:
# of Stories in Building:
Are You in the City Limits?
Yes
No
If "No" above, what fire dept responds?:
Year Building Built:
If over 25 yrs, list years and extent of updates to wiring, plumbing, roof:
Square Footage You Occupy:
Do You Have a Central Station Alarm?
Yes
No
Construction of Bldg:
If Other:
Replacement Cost of Building if owned by you:
$
Business Personal Property:
Replacement Cost: $ (excludes stock)
Tenant Improvements and Betterments:
Replacement Cost: $
Wholesale Value
Retail Value
% of Stock Imported
Inventory/Stock:
$
$
%
Have you had continuous coverage in last 3 yrs?
Yes
No
If "yes", with whom?:
If "yes", Policy #:
Have you had any claims in last 3 yrs?
Yes
No
How many years retail management/ownership experience?
Please provide details as to type of experience:
What are the annual gross sales?
$ (Project next 12 months if you are new in business)
Percentage of sales due to installation or outside services:
%
LOCATION #2
Physical Address:
City:
State:
Zip:
County:
# of Stories in Building:
Are You in the City Limits?
Yes
No
If "No" above, what fire dept responds?:
Year Building Built:
If over 25 yrs, list years and extent of updates to wiring, plumbing, roof:
Square Footage You Occupy:
Do You Have a Central Station Alarm?
Yes
No
Construction of Bldg:
If Other:
Replacement Cost of Building if owned by you:
$
Business Personal Property:
Replacement Cost: $ (excludes stock)
Tenant Improvements and Betterments:
Replacement Cost: $
Wholesale Value
Retail Value
% of Stock Imported
Inventory/Stock:
$
$
%
Have you had continuous coverage in last 3 yrs?
Yes
No
If "yes", with whom?:
If "yes", Policy #:
Have you had any claims in last 3 yrs?
Yes
No
How many years retail management/ownership experience?
Please provide details as to type of experience:
What are the annual gross sales?
$ (Project next 12 months if you are new in business)
Percentage of sales due to installation or outside services:
%
LOCATION #3
Physical Address:
City:
State:
Zip:
County:
# of Stories in Building:
Are You in the City Limits?
Yes
No
If "No" above, what fire dept responds?:
Year Building Built:
If over 25 yrs, list years and extent of updates to wiring, plumbing, roof:
Square Footage You Occupy:
Do You Have a Central Station Alarm?
Yes
No
Construction of Bldg:
If Other:
Replacement Cost of Building if owned by you:
$
Business Personal Property:
Replacement Cost: $ (excludes stock)
Tenant Improvements and Betterments:
Replacement Cost: $
Wholesale Value
Retail Value
% of Stock Imported
Inventory/Stock:
$
$
%
Have you had continuous coverage in last 3 yrs?
Yes
No
If "yes", with whom?:
If "yes", Policy #:
Have you had any claims in last 3 yrs?
Yes
No
How many years retail management/ownership experience?
Please provide details as to type of experience:
What are the annual gross sales?
$ (Project next 12 months if you are new in business)
Percentage of sales due to installation or outside services:
%
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
Name
Title
% Ownership
Payroll
$
$
$
$
$
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
Year
Make
Model
VIN Number
Cost New1
Deductibles2 Comp/Collision
County
Auto #1
$
$ /
$
Auto #2
$
$ /
$
Auto #3
$
$ /
$
Auto #4
$
$ /
$
Auto #5
$
$ /
$
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
Driver #2
Driver #3
Driver #4
Driver #5
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:
Other Amount:
$
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:
Date:
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completed the General Information section at the top of this form.
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