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Home » Commercial Insurance Form

Commercial Insurance Form

Submit our commercial insurance intake form and one of our agents will be in touch.

Commercial Insurance Form

"*" indicates required fields

Step 1 of 7

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Business Information

Proposed Effective Date

MM slash DD slash YYYY Proposed Effective Date

Business Name*

Business Name*

DBA (If Applicable)

DBA (If Applicable)

Principal Contact Full Name*

Principal Contact Full Name

First Name* Last Name*

Primary Phone*

Primary Phone*

Business Mailing Address

Street Address Address Line 2 City State ZIP Code

Email

Email

Tax ID

Tax ID

Legal Entity (Check one)

Corporation

LLC

Partnership

Individual

Not-For-Profit

Other

Business Ownership

Ownership %

Ownership %

List each owner and percentage of ownership.

Primary Owner's Experience in Industry

Primary Owner's Experience in Industry

Inspection Contact

Inspection Contact Name

First Name Last Name

Inspection Contact Phone Number

Inspection Contact Phone Number

Inspection Contact Email

Inspection Contact Email

Accounting Contact

Accounting Contact Name

First Name Last Name

Accounting Contact Phone Number

Accounting Contact Phone Number

Accounting Contact Email

Accounting Contact Email

Description of Operations

Description of Operations

Year Business was Established

Year Business was Established

Years of Owner’s Experience in Industry

Years of Owner’s Experience in Industry

Pay and Employees

Estimated Gross Annual Revenue

Estimated Gross Annual Revenue

Estimated Gross Annual Payroll

Estimated Gross Annual Payroll

Total Number of Employees

Total Number of Employees

How Many Full Time?

How Many Full Time?

How Many Part-Time?

How Many Part-Time?

Current Liability Insurance

Name of Current Liability Insurance Carrier

Name of Current Liability Insurance Carrier

Policy Expiration Date

MM slash DD slash YYYY Policy Expiration Date

Retroactive Date (If any)

MM slash DD slash YYYY Retroactive Date (If any)

Current Liability Limits

Current Liability Limits

Current Property Insurance

Name of Current Property Insurance Carrier

Name of Current Property Insurance Carrier

Policy Expiration Date

MM slash DD slash YYYY Policy Expiration Date

Current Property Limits

Current Property Limits

Coverage Requested

Insurance Coverage Requested (Check all that apply)

Commercial Auto

Employers Practices Liability

Bond

Windstorm

Business Owners Policy (BOP)

Product Liability

Commercial General Liability

Cyber Liability

Professional Liability

Crime

Data Breach Liability

Directors & Officers Liability

Other

If other, please specify

If other, please specify

Liability Limits Desired

Occurrence: $1,000,000 / Annual Aggregate: $2,000,000

Occurrence: $2,000,000 / Annual Aggregate: $4,000,000

Occurrence: $3,000,000 / Annual Aggregate: $6,000,000

Additional Insured(s) Required

Yes

No

Waiver of Subrogation?

Yes

No

Hired & Non-owned Auto?

Yes

No

Professional Liability?

Yes

No

Property Details

Are you the Owner of Building?

Yes

No

f yes, please state total Square Feet of Building

f yes, please state total Square Feet of Building

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

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

Property Coverage and Limits Desire

Building Limit

Building Limit

Business Personal Property (BPP) Limit

Business Personal Property (BPP) Limit

Business Income Limit

Business Income Limit

Stock Limit

Stock Limit

Spoilage Limit

Spoilage Limit

Equipment Breakdown Limit

Equipment Breakdown Limit

Ordinance or Law Coverage

Ordinance or Law Coverage

AOP Deductible

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

Building Construction Type

Number of Stories

Number of Stories

% Sprinklered

% Sprinklered

Building Within City Limits?

Yes

No

Year Built

Year Built

State Year of All Building Updates

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

Roof

Roof

Electrical

Electrical

Plumbing

Plumbing

Heating/AC

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

MM slash DD slash YYYY Date of Birth

Drivers License #

Drivers License #

Year

Year

Make

Make

Model

Model

VIN

VIN

Additional drivers and vehicles or coverage needs

Additional drivers and vehicles or coverage needs

Consent*

I agree to the privacy policy.

I agree to the BluePrint Risk privacy policy https://blueprint-risk.com/privacy-policy/ and provide my consent to be called, emailed or texted by BluePrint Risk.

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