Commercial Insurance Form

Business Information

Proposed Effective Date

Business Name

DBA (If Applicable)

Principal Contact Full Name

First Name Last Name

Primary Phone

Business Mailing Address

Street Address Address Line 2 City State ZIP Code

Email

Tax ID

Legal Entity (Check one)

Business Ownership

Ownership %

List each owner and percentage of ownership.

Primary Owner's Experience in Industry

Inspection Contact

Inspection Contact Name

First Name Last Name

Inspection Contact Phone Number

Inspection Contact Email

Accounting Contact

Accounting Contact Name

First Name Last Name

Accounting Contact Phone Number

Accounting Contact Email

Description of Operations

Year Business was Established

Years of Owner’s Experience in Industry

Pay and Employees

Estimated Gross Annual Revenue

Estimated Gross Annual Payroll

Total Number of Employees

How Many Full Time?

How Many Part-Time?

Current Liability Insurance

Name of Current Liability Insurance Carrier

Policy Expiration Date

Retroactive Date (If any)

Current Liability Limits

Current Property Insurance

Name of Current Property Insurance Carrier

Policy Expiration Date

Current Property Limits

Property Details

Are you the Owner of Building?

Yes

No

f yes, please state total Square Feet of Building

If you are a Tenant, please state Total Square Feet of your leased space

Property Coverage and Limits Desire

Building Limit

Business Personal Property (BPP) Limit

Business Income Limit

Stock Limit

Spoilage Limit

Equipment Breakdown Limit

Ordinance or Law Coverage

AOP Deductible

Sub-limit for Theft Coverage is available ONLY with a Central Station Burglar Alarm System.

Premises Location & Building Information

Location

Street Address Address Line 2 City State ZIP Code

Building Construction Type

Number of Stories

% Sprinklered

Building Within City Limits?

Yes

No

Year Built

State Year of All Building Updates

Year Renovated (Mandatory if building is greater than 10 years old)

Roof

Electrical

Plumbing

Heating/AC

Select all that apply

Building Security Fire Alarm

Central Station Burglar Alarm

None

Smoke Detectors

Yes - Battery

Yes - Hardwired

No

Commercial Auto

Driver

First Name Last Name

Date of Birth

Drivers License #

Year

Make

Model

VIN

Additional drivers and vehicles or coverage needs

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