"*" indicates required fields Step 1 of 5 20% Business DetailsBusiness Name:**Please list your entity name or personal name if you are a sole proprietor. *PLEASE ADD LLC or INC at the end of business name based on the entity type.Business Website:Business EntityIndividual/Sole ProprietorLLCINCPartnershipOtherFEIN / Tax-ID Number or Social Security NumberBusiness Phone Number:*Business Contact Email:* Primary Contact Name First Last Primary Contact Phone Number:*Primary Contact Email:* Names and % of Ownership for all Officers:Full NamePosition% of Ownership Add RemoveMailing Address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is Physical Address Same As Mailing Address? Yes No Location Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Years of ExperienceRequested Effective Date: MM slash DD slash YYYY Year Business Started:Coverage(s) Needed Business Auto Building/Property Cyber Liability General Liability Workers Comp Inland Marine Are You A Contractor? Yes No Do you use multi-factor authentication? Yes No Do you currently carry cyber liability? Yes No Current Cyber CarrierNumber of Full-Time Employees:Number of Part-Time Employees:General Liability Limits Requested$100,000$200,000$300,000$500,000$1,000,000$2,000,000Owners can exclude themselves from coverage. Yes No Estimated Total Payroll:(not including any owners payroll)Please provide a detailed description of business operations:*Please list ALL operations of the company.Additional Contractor DetailsContractors License #% of work Subcontracted out% of Residential Work% of Commercial Work% of Remodel/Install work% of New Construction Work% of Service/Maintenance WorkDo you perform Government/Municipality Work?YesNo Business Auto InformationHow many vehicles are owned by the business?1234567891011+How many trailers are owned by the business?1234567891011+How many drivers work for the business?1234567891011+Current Carrier:Current Payment Plan:Vehicle #1Year*Make*Model*Vehicle #1 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage DeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Vehicle #2Year*Make*Model*Vehicle #2 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage DeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Vehicle #3Year*Make*Model*Vehicle #3 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage DeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Vehicle #4Year*Make*Model*Vehicle #4 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage DeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Vehicle #5Year*Make*Model*Vehicle #5 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage DeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Vehicle #6Year*Make*Model*Vehicle #6 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage DeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Vehicle #7Year*Make*Model*Vehicle #7 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage DeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Vehicle #8Year*Make*Model*Vehicle #8 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage DeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Vehicle #9Year*Make*Model*Vehicle #9 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage DeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Vehicle #10Year*Make*Model*Vehicle #10 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage DeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Trailer #1YearMakeModelTrailer ValueLengthIs trailer enclosed? Yes No Trailer #1 VINTrailer #2YearMakeModelTrailer ValueLengthIs trailer enclosed? Yes No Trailer #2 VINTrailer #3YearMakeModelTrailer ValueLengthIs trailer enclosed? Yes No Trailer #3 VINTrailer #4YearMakeModelTrailer ValueLengthIs trailer enclosed? Yes No Trailer #4 VINTrailer #5YearMakeModelTrailer ValueLengthIs trailer enclosed? Yes No Trailer #5 VINTrailer #6YearMakeModelTrailer ValueLengthIs trailer enclosed? Yes No Trailer #6 VINTrailer #7YearMakeModelTrailer ValueLengthIs trailer enclosed? Yes No Trailer #7 VINTrailer #8YearMakeModelTrailer ValueLengthIs trailer enclosed? Yes No Trailer #8 VINTrailer #9YearMakeModelTrailer ValueLengthIs trailer enclosed? Yes No Trailer #9 VINTrailer #10YearMakeModelTrailer ValueLengthIs trailer enclosed? Yes No Trailer #10 VINDriver #1Name First Last DL#Date of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Driver #2Name First Last DL#Date of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Driver #3Name First Last DL#Date of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Driver #4Name First Last DL#Date of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Driver #5Name First Last DL#Date of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Driver #6Name First Last DL#Date of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Driver #7Name First Last DL#Date of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Driver #8Name First Last DL#Date of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Driver #9Name First Last DL#Date of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Driver #10Name First Last DL#Date of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Please Upload any additional DriversMax. file size: 98 MB. Please Upload any additional VehiclesMax. file size: 98 MB. Please Upload any additional TrailersMax. file size: 98 MB. Building/PropertyCurrent CarrierInterest in Building: Owner Tenant % of building occupied:% leased to others:Foundation Type: Slab Crawl Space Basement Building type: Frame Masonry If frame what type of siding? Wood Vinyl Stories: 1 2 3 4 5 6 7 8 9 10 Total Square Feet:Roof Age:Roof Type Shingles Wood Shingles Metal Clay Tiles Flat Roof Age of Wiring:Plumbing:Heating:Sprinkler System: Yes No Need Sign Coverage: Yes No Amount of CoverageIs there a Premises Alarm Active? Yes No Value of Personal Contents:Coverage Limit for Building:Coverage RequestedReplacement CostActual Cash Value(Actual Cash Value Claim payout is depreciated based on age of property)Number of Buildings1234567891011121314151617181920 Inland MarineTools/Equipment coverage needed?Blanket limit for small tools (for any tool that is valued $2499 and below per each tool)$2500 and up.Amount of Coverage NeededListItem DescriptionValue Add Remove Assigned AdvisorAmanda ChenNicki ReynaGerald ShopeKortni SchmittTyson ClarkApril HolmesWho Filled Out The Intake***FOR INTERNAL USE ONLY Upload DocumentsMax. file size: 98 MB.
