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Commercial Insurance Application
Commercial Insurance Application
Name:
(First)
(Middle)
(Last)
Other Named Insured:
(First)
(Middle)
(Last)
Mailing Address:
(Street Address)
(City)
(State)
(Zip)
Property Address (if different mailing):
(Street Address)
(City)
(State)
(Zip)
Telephone Number:
Email Address:
Website Address:
FEIN or Social Security #:
Retail %:
Wholesale %:
Importing %:
Type of company
Individual
Partnership
Corporation
Joint Venture
Subchapter "S" Corporation
Not For Profit Organization
LLC
Date Business Started:
(mm)
(dd)
(yy)
# of Years in this Industry:
Current Insurance Information
Current Insurance Carrier:
Policy #
Premium:
Expired Date:
(mm)
(dd)
(yy)
Premises Information
Building #1
Address:
(Street Address)
(City)
(State)
(Zip)
Ownership
Owner
Tenant
Nature of Business/Description of Operations by Premises:
Year Built:
Number of Employees:
Percentage Occupied:
Square Footage:
Number of Stories:
Number of Apt. Units:
Construction of the Building:
Brick
Stucco
Frame
Other:
Burglar Alarm:
None
Local
Central
Smoke Detector Alarm:
None
Local
Central
Year of Update for:
Roof:
Elec:
Heat:
Plumbing:
Limits
Building:
Contents:
Business Income:
Improvements & Betterments:
Deductible:
Employees:
#Males:
#Females:
Payroll:
Sales:
Name of Mortgagee &/or Landlord and Address:
Optional Coverage
Glass Coverage:
Yes
No
Linear feet:
Building #2
Address:
(Street Address)
(City)
(State)
(Zip)
Ownership
Owner
Tenant
Nature of Business/Description of Operations by Premises:
Year Built:
Number of Employees:
Percentage Occupied:
Square Footage:
Number of Stories:
Number of Apt. Units:
Construction of the Building:
Brick
Stucco
Frame
Other:
Burglar Alarm:
None
Local
Central
Smoke Detector Alarm:
None
Local
Central
Year of Update for:
Roof:
Elec:
Heat:
Plumbing:
Limits
Building:
Contents:
Business Income:
Improvements & Betterments:
Deductible:
Employees:
#Males:
#Females:
Payroll:
Sales:
Name of Mortgagee &/or Landlord and Address:
Optional Coverage
Glass Coverage:
Yes
No
Linear feet:
Umbrella Policy Coverage:
Yes
No
1 Million
2 Million
3 Million
Other:
*Please attach supplementary sheets for additional premises.
General Information
Is the applicant a subsidiary of another entity?
Yes
No
Does the applicant have any subsidiaries?
Yes
No
Is a formal safety program in operation?
Yes
No
Any exposure to flammables, explosives, chemicals?
Yes
No
Any catastrophe exposure?
Yes
No
Any other insurance with this company or being submitted?
Yes
No
Any policy or coverage declined, cancelled or non-renewed during the prior 3 years?
Yes
No
If yes, please state reason:
Any past losses or claims relation to sexual abuse or molestation allegations, discrimination or negligent hiring?
Yes
No
During the last five years, has any applicant been convicted of any degree of the crime of arson?
Yes
No
Any uncorrected fire code violations?
Yes
No
Any bankruptcies, tax or credit liens against the applicant in the past 5 years?
Yes
No
Has business been placed in a trust?
Yes
No
Name of trust:
If answer is ‘yes’ to any of the above questions, please state reason below:
Question#:
Reason:
Loss History
Address:
(Street Address)
(City)
(State)
(Zip)
Date of Occurence:
(mm)
(dd)
(yy)
Type/Description of occurence or claim:
Date of Claim:
(mm)
(dd)
(yy)
*Note: Five year loss history required.
*Please attach supplementary sheets for additional premises.
