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Personal Information
Owner's First Name
*
Owner's Last Name
*
Email Address
*
Primary Phone Number
*
Fax Number
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Business Name
*
DBA
Business Address
*
Check here if your mailing address is the same as your business Address
Mailing Address
*
Business Ownership Type
*
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Sole Proprietorship
Partnership
LLC
Corporation
Joint Venture
Trust
Association
Municipality
Other
Please type in Ownership Type
*
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Does your business have a Federal Employer Identification Number (FEIN)?
Yes
No
Federal Employer Identification Number (FEIN)
*
Social Security Number (SSN) (Required only for sole proprietary)
Primary type of your business
*
Job Description
Class Code
Number of Employees
Annual Payroll
Job Description
Class Code
Number of Employees
Annual Payroll
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Class Code
Number of Employees
Annual Payroll
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Class Code
Number of Employees
Annual Payroll
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Total Number of Employees
*
Number of Full Time Employees
*
Number of Part Time Employees
*
Number of Active Partners/Officers
Does this number include officers in Workers Comp?
Yes
No
Total Annual Payroll (excluding owners and subcontractors)
*
Total Gross Income
Years of Industry Experience
In what year did you start your business?
Is the business a 24 hours operation?
Yes
No
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Have you had any Prior Carrier?
*
Yes
No
Name of the Prior Carrier
*
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Travelers
Hartford
Farmers
State Farm
All State
Chubb Corp.
CNA
Fireman’s Fund
Guard
AIG
CIG
Allied/Nationwide Insurance
ACE
Lloyds
Other
Please Specify Prior Carrier
*
Policy Expiration Date(MM-DD-YYYY):
*
Policy Number (Optional):
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Have there been losses for the lines of business submitted in the last 4 years?
*
Yes
No
Please attach a copy of Loss Run from your prior Carriers in the last 4 Years
*
Do you carry Group Health Insurance?
*
Yes
No
Name of the Company
*
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Does the applicant own, operate, or lease aircraft/watercraft?
Yes
No
Any exposure to flammables, explosives, caustics, and fumes?
Yes
No
Any exposure to radioactive materials?
Yes
No
Any work performed underground or above 15 feet?
Yes
No
Any work performed on barges, vessels, and docks?
Yes
No
Is the applicant engaged in any other type of business?
Yes
No
Are subcontractors used?
Yes
No
Any work sublet without certificates of insurance?
Yes
No
Any group transportation provided?
Yes
No
Any employees under 16 or over 50 years of age?
Yes
No
Any employees over 60 years of age?
Yes
No
Any part-time or seasonal employees?
Yes
No
Is there any volunteer or donated labor?
Yes
No
Any employees with physical handicaps?
Yes
No
Do employees travel out of state?
Yes
No
Are athletic teams sponsored?
Yes
No
Are pre-employment physicals required?
Yes
No
Any other insurance with this insurer?
Yes
No
Any prior coverage declined/canceled/non-renewed in the last 3 years?
Yes
No
Certified Risk Management Program?
Yes
No
Certified Risk Management Program?
Yes
No
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