Commercial Insurance Application

Indicate coverage required for quoting:

Property
Crime
Transportation
Equipment Floater
EDP
General Liability
Business Auto
Boiler & Machinery
Workers Comp
Umbrella


Applicant Information:
Name
Address City State Zip Code
Business Phone E-mail Address
Proposed Eff Date: Month Day
FEIN Num
SIC Code
Total Employees Part-time Employees # of Shifts
Nature of Business

Workers Comp
Eff Date Month Day
Normal Anniversary Rating Date
WC States
Employer Liab Limits

State/Loc
Class code
Categories
Payroll
/
/
/
/
/
/


General Liability
Eff Date: Month Day
Claims/Occurrence Form
General Agg Limit
Products Limit
Personal & Advertising Limit
Fire Damage Limit
Medical Limit
Employee Benefits Limit

Classification
Class code
Premium basis (P=payroll/S=sales/A=area)

 

Property

Eff Date: Month Day
Coins%
Valuation
Cause of Loss
Deductible Other
Premise Burglar Alarm: Yes No
Premise Sprinklered: Yes No

Location City/State Building Limit Personal Prop Limit Sq/ft of building
/
/
/
/
/
/


Business Auto

Eff Date: Month Day
Number of Vehicles
Number of Autos
Number of trucks
Number of trailers

How is vehicles used? (Personal, Service, Commercial or Retail)

Coverage Information

Coverages Limits
Bodily Injury 20,000/40,000
Personal Injury Protection. 8,000
Opt. Bodily Injury
Property Damage
Medical Payments
Uninsured Motorists
Underinsured Motorists
Comprehensive
Collision
Limited Collision
Loss Of Use
Towing


Umbrella

Eff Date: Month Day
Limit of Umbrella
Retention Limit Other

Estimated Total Commercial Premium