Commercial Package Application

Commercial Package Application - (Page: 1 of 4)

This is a BOP Application - We must have property to value information.

EPLI Available.
(Please request application from (800) 400-3276)

Please complete the form below and click the submit button to complete the application.

Fields marked with (*) are required fields.

Browser Compatibilty

Application works only in Microsoft Internet Explorer - Compatability View and Mozilla Firefox, does not work in Google Chrome

Agent Information

Agency*

Agent Name*

Agent Phone*

Fax*

Email Address*

Would you like the quote sent?* Fax Email

Policy Information

Proposed Effective Date*

Proposed Expiration Date*

Application Information

Business Name*

Owner(s) Name*

Does this entity own other businesses or buildings not covered by this policy? If yes, please describe*

Type of Business*

Phone (Area Code, Number & Ext.)*

Current / Prior Carrier: (Include Company Name, Coverage Types, Line of Business and Dates.)*

Has policy been cancelled or non-renewed in past 3 years? If yes, please describe* Yes No

If yes, please describe

Any claims in the last 4 years? (Package Only) (Depending on class of business; carrier may require 5 years hard copy loss history in order to quote.)* Yes No

If yes, please explain and include : Description Date Amount Paid What has been done since to prevent a reoccurence?

Commercial Package Application - (Page: 2 of 4)

Fields marked with (*) are required fields.

Location

Location Address: (Include County & Zip)*

Years in Business*

Years of Experience

Mailing Address: (Only if different than location address above. - Include City, State & Zip)*

Interest

Square feet occupied by the insured:*

Total square feet of the entire building or strip center: (Also include number of Stories)*

Year Built*

Please List Building Improvements: Building updates required for all buildings 25 years or older

Wiring Year

Roofing Year

Plumbing Year

Heating Year

Is this business the sole occupant of a free standing building: (Excludes home based business)* Yes No

Sprinklers?* Yes No

Central Station Alarm?* Yes No

Nature of Business

Classification of Business: (Short Version)*

Business Web Site Address: (If Any)

Gross Annual Receipts: (Annual Rent for Lessors Risk - This is Gross, Not Net)*

Description of Operations / Occupancy: (Be as detailed as possible - 10 words minimum!) (All Tenants with Sq. Ft. for Lessors Risk)*

Does this prospect do any installation?* Yes No

Professional Liability in place? (If Applicable) If Yes, please complete: Yes No

Company

Effective Dates

Policy Number

Commercial Package Application - (Page: 3 of 4)

Fields marked with (*) are required fields.

Property (Must be to value - All Property.)

Deductible preferred:*

Building Coverage Amount

Tenant Improvements and Betterments: (permanently installed bpp)

Is this a triple net lease?* Yes No

If so, limit for building coverage

If so, limit for liability coverage

Number of Stories*

Type of Construction*

Percentage of Products Sold that are directly imported. (Wholesale Only)*

Personal Property Coverage Amount

Property and Crime Coverage Number of Employees:

Full Time*

Part Time*

Have you asked your client about:

Commerical Automobile Coverage?* Yes No

Commercial Umbrella Coverage? Please Send Accord* Yes No

Workers Compensation Coverage? Please See Below To Get Quote* Yes No

Technology & Misc. E&O, D&O, EPL* Yes No

Contact Us For Qualification & Application For Markets, Grocery Stores & Restaurants.

Spoilage Coverage

Spoilage Limit: $

Deductible

Food Contamination Limit

Annual Food Gross Receipts: $

Commercial Package Application - (Page: 4 of 4)

Fields marked with (*) are required fields.

General Liability Limits

General Aggregate

Products & Completed Operations Aggregate: $

Personal & Advertising Injury: $

Each Occurance

Damage To Rented Premises

Is employee benefits coverage needed?* Yes No

Garagekeepers For Auto Repair and Stereo Installation

Comprehensive Limit: $

Collision Limit: $

Coverage Basis:

Comprehensive Deductible: $500 / $2500

Collision Deductible: $500 / $2500

Liquor Liability

Liquor Liability Yes No

Annual Liquor Gross Receipts

Workers Compensation (For Any Losses In Past 3 Years, Please Get Loss Runs)

FEIN Number (Must have a FEIN to get a W/C quote.)

Enter Class of Employees - i.e.: Clerks, Retail, Labor, etc. into first box
Enter Annual Payroll For Each Class into second box

class1

class2

class3

Officers/Directors Exclusion

Name of excluded person, Title, Ownership %, Duties

Experience Modification If Applicable (Must have or can get documentation)

What is your target for Workers Compensation?

Effective Date:

Have there been any losses in the last 3 years? If so, please send Loss Runs Yes No

Additional Interests

(Landlords & Property Managers - Mortgagees, Loss Payees, etc.)

Additional Comments

What is your target premium on package? $

Any person who knowingly and with intent to defraud any insurance company or another person files an application for Insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal civil penalties. The undersigned is an authorized representative of the applicant and represents that reasonable enquiry has been made to obtain the answers to questions on this application. He/She represents that the answers are true, correct and complete to the best of his/her knowledge.

Applicant Signature/Print Name

Agent/Producer Signature/Print Name

Attachments

Please attach any additional documents needed for your submission, click the folder below to select one or more files.

Commercial Package Application - (Page: Review)

Your application has not been submitted yet. Please review all of your answers below and

click the submit button at the bottom of this page to complete your application

Agency

Agent Name

Agent Phone

Fax

Email Address

Would you like the quote sent

Proposed Effective Date

Proposed Expiration Date

Please indicate all lines of coverage needed for quote

If Other, Please fill in the type

Business Name

Owner(s) Name

Does this entity own other businesses or buildings not covered by this policy? If yes, please describe

Type of Business

Phone (Area Code, Number & Ext.)

Current / Prior Carrier: (Include Company Name, Coverage Types, Line of Business and Dates.)

Has policy been cancelled or non-renewed in past 3 years? If yes, please describe

If yes, please describe

Any claims in the last 3 years? (Package Only)

If yes, please explain and include : Description Date Amount Paid What has been done since to prevent a reoccurence?

Location Address: (Include County & Zip)

Years in Business

Years of Experience

Mailing Address: (Only if different than location address above. - Include City, State & Zip)

Interest

Square feet occupied by the insured:

Total square feet of the entire building or strip center: (Also include number of Stories)

Year Built

Wiring Year

Roofing Year

Plumbing Year

Heating Year

Is this business the sole occupant of a free standing building: (Excludes home based business)

Sprinklers?

Central Station Alarm?

Classification of Business: (Short Version)

Business Web Site Address: (If Any)

Gross Annual Receipts: (Annual Rent for Lessors Risk - This is Gross, Not Net)

Description of Operations / Occupancy: (Be as detailed as possible - 10 words minimum!) (All Tenants with Sq. Ft. for Lessors Risk)

Does this prospect do any installation?

Professional Liability in place? (If Applicable) If Yes, please complete:

Company

Effective Dates

Policy Number

Deductible preferred:

Building Coverage Amount

Is this a triple net lease?

If so, limit for building coverage

If so, limit for liability coverage

Number of Stories

Type of Construction

Percentage of Products Sold that are directly imported. (Wholesale Only)

Personal Property Coverage Amount

Full Time

Part Time

Commerical Automobile Coverage?

Commercial Umbrella Coverage? Please Send Accord

Workers Compensation Coverage? Please See Below To Get Quote

Technology & Misc. E&O, D&O, EPL

Spoilage Limit: $

Deductible

Food Contamination Limit

Annual Food Gross Receipts: $

General Aggregate

Products & Completed Operations Aggregate: $

Personal & Advertising Injury: $

Each Occurance

Damage To Rented Premises

Is employee benefits coverage needed?

Comprehensive Limit: $

Collision Limit: $

Coverage Basis:

Comprehensive Deductible: $500 / $2500

Collision Deductible: $500 / $2500

Liquor Liability

Annual Liquor Gross Receipts

FEIN Number (Must have a FEIN to get a W/C quote.)

class1

$

class2

$

class3

$

Name of excluded person, Title, Ownership %, Duties

Experience Modification If Applicable (Must have or can get documentation)

What is your target for Workers Compensation?

Effective Date:

Have there been any losses in the last 3 years? If so, please send Loss Runs

(Landlords & Property Managers - Mortgagees, Loss Payees, etc.)

Additional Comments

What is your target premium on package? $

Applicant Signature/Print Name

Agent/Producer Signature/Print Name

Please insert appropriate characters to submit request

Commercial Package Application - (Complete)

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