Business Owners Package Application

Business Owners Package Application
Insured's Name First Last
Mailing Address
Street Address

Address Line 2

City

State

Zip Code
Location Address
Street Address

Address Line 2

City

State

Zip Code
Proposed Effective Date / MM / DD YYYY
Expiration Date / MM / DD YYYY
Company Type
If other, please describe:
Number of years in business
Number of years with experience
Inspection Contact First Last
Phone Number - (###) - ### ####
Hours of Operation
Nature of business/description of operations by premise(s) in detail, including a web address (include primary customers and intended use of product):
Does insured operate any other business or own any property other than the premises listed here? If yes, describe the operation and the location address:
BUILDING INFORMATION
Building
Value: $
Business Contents
Value: $
Business Income/Annual Loss of Rents value: $
Deductible desired: $
Occupancy
Sq. footage occupied
Total Sq.
footage
Other occupancies
in the building
Construction
(i.e. frame, masonry, etc.):
Sprinklered Yes No
Alarm none local central station
UL certified Yes No
Year built
# of stories
# of units
basement
Building improvements (year completed)
Wiring
Roofing
Plumbing
Heating
Any private protection system (explain)
COMPANY INFORMATION:
Annual projected gross sales/receipts: $
Percentage from the internet: %
Any (check all that apply) mortgagees loss payees additional insured
If so, please provide details:
Please provide the required 5 years of loss runs, if applicable
Current company
Expiring premium (if known): $
BUSINESS AUTOMOBILE INFORMATION:
Year, Make/Model, Vehicle Indentification #, Cost New, Garaged (city,state,zip)
Physical Damage Coverage:
Comprehensive deductible: $
Collision deductible : $
Driver's Name, Date of Birth, License No., State (one driver per line)
Do family members use vehicles? (if yes, please include family member information too, on above list) Yes No
Are any of the vehicles listed above not owned or registered to the insured? Yes No
If yes, please explain:
Do any employees use their own vehicles for the insured operations? Yes No
How often?
Any outside salespeople or drivers? Yes No
If yes, how many?
Distance traveled a month? (include their driver information)
Does the insured pre-screen drivers upon employment? (MVR) Yes No
Is there a routine mechanical maintenance program in place? Yes No
WORKERS COMPENSATION INFORMATION:
Federal Employee Indentification Number
Annual payrolls by classification (examples: sales, office, manufacturing, etc.). Also list the # of full and part time employees.
Employer's Liability Limit Desired (in thousands):
Any employee under 16 or over 60 years of age? Yes No
If yes, please describe:
Any employees with physical handicaps? Yes No
If yes, please describe:
Any volunteers or donated labor? Yes No
If yes, please describe:
Any leasing of employees to or from others? Yes No
If yes, please describe:
Describe any safety/training programs being used:
Any Partners, Officers, Relatives to be excluded: provide names, titles and % ownership in company:
Umbrella Limit

Business Owners Package Application

Business Owners Package Application

Business Owners Package Application

BUILDING INFORMATION

Building improvements (year completed)

COMPANY INFORMATION:

Please provide the required 5 years of loss runs, if applicable

BUSINESS AUTOMOBILE INFORMATION:

Physical Damage Coverage:

WORKERS COMPENSATION INFORMATION: