New Business Insurance Application

GENERAL INFORMATION

Legal Name of Business *

Contact Name *

Address *

City *

State *

Zip *

Phone Number *

Fax *

Email *

Website *

Date Business Started *

Month

Day

Year

If new venture, how many years of experience does the owner/manager have in this type of business *

Detailed Description of Operations *

Type of Business (Corporation, Not for Profit, Partnership, Sole Proprietorship, etc.) *

Current Expiration Date or Date you would like coverage to be effective *

Month

Day

Year

How many years of previous insurance coverage *

Current Insurance Company *

*IF ALREADY IN BUSINESS, PLEASE ATTACH MINIMUM OF 3 YEARS LOSS RUNS FOR ALL POLICIES* *

Files must be less than 8 MB.
Allowed file types: gif jpg jpeg png pdf doc docx odt ppt pptx xls xlsx.

Coverages Desired (Complete each section below for desired coverage) *

BUSINESS AUTOMOBILE

Number of Vehicles *

Vehicle 1

Year *

Make/Model *

VIN *

Garaging Location *

Cost New *

Vehicle Use *

Vehicle 2

Year *

Make/Model *

VIN *

Garaging Location *

Cost New *

Vehicle Use *

Vehicle 3

Year *

Make/Model *

VIN *

Garaging Location *

Cost New *

Vehicle Use *

Vehicle 4

Year *

Make/Model *

VIN *

Garaging Location *

Cost New *

Vehicle Use *

Do employees use their personal auto for company business? *

Yes

No

If yes, # of employees: *

Do key employees use company cars with no personal auto policy? *

Yes

No

If yes, provide names of employees: List of Drivers *

Driver 1

Name (First, Middle, Last) *

Date of birth *

Month

Day

Year

Driver’s License Number *

State *

Driver 2

Name (First, Middle, Last) *

Date of birth *

Month

Day

Year

Driver’s License Number *

State *

Driver 3

Name (First, Middle, Last) *

Date of birth *

Month

Day

Year

Driver’s License Number *

State *

Driver 4

Name (First, Middle, Last) *

Date of birth *

Month

Day

Year

Driver’s License Number *

State *

Driver 5

Name (First, Middle, Last) *

Date of birth *

Month

Day

Year

Driver’s License Number *

State *

COMMERCIAL PROPERTY

Premises Location(s) *

Building Owner or Tenant *

If tenant, attach copy of lease agreement. Sprinklered? *

Files must be less than 8 MB.
Allowed file types: gif jpg jpeg png pdf doc docx odt ppt pptx xls xlsx.

Building Year *

Total Building Sq Ft *

Occupied Area *

Alarm System? *

When were the following systems updated?

Heating *

Electrical *

Roof *

Plumbing *

Building Construction Type *

Desired Limits

Building *

Business Personal Property *

Property of Others in your custody *

Tenant’s Improvements & Betterments *

Business Income *

Computer Hardware & Data/Media *

Loss Payee or Mortgagee? *

Security Precautions in place *

WORKERS COMPENSATION & TDI

Federal ID *

DOL# *

Experience Mod

No. of Payroll Info *

Payroll Info 1

Classification *

Payroll *

# Full-Time *

# Full-Time # Part-Time *

Payroll Info 2

Classification *

Payroll *

# Full-Time *

# Full-Time # Part-Time *

Payroll Info 3

Classification *

Payroll *

# Full-Time *

# Full-Time # Part-Time *

No. of Officer Info *

Officer Info 1

Name *

Title *

% Ownership *

Duties *

Included/Excluded *

Officer Info 2

Name *

Title *

% Ownership *

Duties *

Included/Excluded *

Please share any additional information, comments, or requests we should be aware of.

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New Business Insurance Application

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