New Business Application
Application Information:

Company name:
Attention:
Street address:
City, State, Zip Code:
Phone:
Fax:
E-mail address:
Web site URL:

Coverage's Requested:

Small Business Package
General Liability
Property
Auto
Workers Compensation
Professional Liability (E&O)
Umbrella/Excess Liability
Other

Effective date requested (mm/dd/yyyy):

Please describe the nature of your business.

General Information:

# Of locations
# of employees
Years in business
Years of Management Experience in Industry
Type of business
Gross receipts
Payroll
# of years insured
General Liability Limit Requested
 
Do you currently have Professional Liability (E&O) insurance coverage in place?  Yes No
Are you a subsidiary of another entity or do you have any subsidiaries?   Yes No
Is a formal safety program in operation?  Yes No
Any exposure to flammables, explosives, or chemicals?  (On or adjacent to your premise.)  Yes No
Any used merchandise sold or for sale?  Yes No
Any policy or coverage declined, cancelled, or non-renewed in the last three years?  Yes No
Have any claims been made against you in the past five years?  Yes No
Do you do more than 25% of your work away from your premise?  Yes No
Do you only need insurance for a specific job or project?  Yes No

Property:

Thank you for your time.