Business Owners Policy Online Application

Name of Business

Type of Business

Contact Name

Phone Number

Street Address

City

County

State

Zip Code

Web address. If you do not have a website, state NONE:

Email Address

Years in business under similiar name?

Do you currently have insurance for your business?
 Yes No

Type of business formation
Please SelectSole ProprietorLLCPartnershipCorporation

Tax ID# or SS# if individual (required)

Please describe in detail about the location you are seeking coverage for. (example-office space in a 8 floor commercial office complex, office space in the basement of my primary residence, deli in a strip mall, office space in a stand alone building of which I am the only business, etc)

If other businesses are located in your building as a whole, what percentage of the entire square footage of the building is unoccupied?

Regarding your building location(s), are you the:
 Owner Tenant Both

If yes, please provide the details of your current coverage. Please provide the name of the carrier, type of coverage, limits, deductibles, expiring premium and renewal date. If none, state NONE.

Regarding Property Insurance, how much in limits for the Building are you seeking?

How much insurance are you requesting to cover your equipment? If none, state NONE.

What is the usable square footage of your business?

What percentage of the entire premises does your business occupy?

If you are in a multi-business location, name the TYPE of business that occupy space, if no other businesses occupy space, state NONE.

What year was the building built?

Construction type of the building:
Please SelectFrameBrickMasonryHardi PlankFire ResistantOther

# of stores, not including basement

Foundation:
Please SelectBasement (Not finished)Basement (Partially finished)Basement (Fully finished)SlabClosed with crawl spaceOpen – Height more than 2 feetOpen – Height less than 2 feetWoodOther

What material is the roof made of?

Primary Heating Method:
Please SelectFurnace (Gase or Electric)Electric BaseboardHeat PumpCoal FurnaceSteamWoodburnerAbove ground tankBelow ground tank

How much Personal Property limits are you seeking? (including business alterations)

How high of a deductible are you willing to accept for Property Insurance?

Is there a boiler on your premises?
 Yes No

Do you have a smoke alarm in the building?
 Yes No

What type of smoke alarm?
Please SelectLinked to the fire departmentNeither

What type of fire protection is on the premises?
Please SelectSprinklersStandpipesCO2/Chemical Systems

Do you have a burglar alarm in the building?
 Yes No

Please advise the most recent year updates were made to the following:
Roof:

Electrical System:

Plumbing System:

HVAC System:

Do you use high power lighting for Photo or Video work?
 Yes No Not applicable

Do you use any toxic or flammable materials in your business?
 Yes No Not applicable

Is the computer equipment protected by fire protection & suppression device?
 Yes No Not applicable

How often do you back up all computer data?
 Daily Weekly Monthly Quarterly No backup necessary

Is back up stored off premises?
 Yes No Not applicable

If yes, provide details. If this does not apply, state N/A.

Is computer equipment & media located above ground level?

Please state the annual gross billings for the most recent 12 month period:

How many employees do you employ?
Full Time:

Part Time:

What is your gross annual payroll?

Please provide a breakdown of your annual payroll by department. (i.e.: office, salespeople, laborers, drivers, etc.)

Do you have any operations other than the business operations described?
 Yes No

If so, please describe below:

Do you have any other additional locations?
 Yes No

If yes, please provide the location address, Building Limits and Personal Property Limits:

Would you like the vehicles used in your business to be covered under the same policy, if possible?
 Yes No

If yes, please provide the following information:
Year:
Make:
Model:
Cost New:
VIN# (17 digits)
Garaged/Parked Location
Zip Code

Please provide the following driver information:
Name:
Date of Birth:
License Number:
State licensed:

Have you have any claims the last 5 years?
 Yes No

If yes, please provide details and how much money was incurred by the carrier:

Would you like a quote for Umbrella Insurance?
 Yes No

If yes, how high of a limit in excess of the primary insurance limit are you seeking?
 $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 more than $5,000,000 excess of the primary insurance

Would you like a quick quote for Employment Practices Liability?
 Yes No

How did you hear about us?

Please SelectGoogleLinkedInLawyers Diary and ManualOther Trade PublicationEmailPostcardNewspaper ADFriendTrade ShowFacebookOther

Did we miss something? Additional Comments:

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