Our Experts Are Available to Help You
Interested In
Areas of Specialization
Business Insurance
Personal Insurance
Employee Benefits
Security Verification
+
=
Submit
Search for
Search
Toggle navigation
MENU
ABOUT US
Who We Are
Testimonials
Careers
Contact Us
CLIENT CENTRAL
HRnet
Claims
Business Clients
Add/Delete A Driver
Add/Delete A Vehicle
Add/Change Location
Personal Clients
Add/Delete A Driver
Add/Delete Vehicle
Insurance Companies/Specialty Markets
REQUEST A QUOTE
Associations and Not-For-Profit
Biotech, Medtech and Life Sciences
Cleaning and Restoration Services
Cyber Liabiity
Directors and Officers Liability
Employment Practices Liability
General Business
General Quick Quote Request
Group Health Employee Census
Group Life & Disability Employee Census
Homeowners
Information Technology
International and Defense Base Act
International Medical and Travel Products
Investment Property
Kidnap & Ransom
Personal Automobile
Professional Cleaning Services Program
Residential Cleaning Services
Blog
(855) 868-0170
Toggle navigation
MENU
AREAS OF SPECIALIZATION
Retail Industry
Non-Profit Organizations and Associations
Professional/Commercial Cleaning Services Program
Technology Industry Professionals
International and Defense Base Act
Management & Professional Liability
Biotech & Life Sciences
Cleaning and Restoration Services
Professional Services – Medical, Legal, Architects, Accountants
Manufacturers, Wholesalers, and Distributors
Contractors – Small, Medium, and Large
Personal High Net Worth Individuals and Families
International Medical and Travel Products
BUSINESS INSURANCE
Overview
Commercial Property & Liability
Business Automobile
Cyber Liability Insurance
Workers’ Compensation
Umbrella Liability
Management & Professional Liability
Business Travel Accident
Surety Bonding
PERSONAL INSURANCE
Overview
Homeowners
Personal Automobile
Personal Umbrella Liability
Valuable Items
Flood Insurance
Watercraft
Motorcycle
Motorhome
Investment Property
Renters Insurance
Individual Life & Disability Insurance
EMPLOYEE BENEFITS
Overview
Group Life Insurance
Group Health Insurance
Group Disability Insurance
Group Dental Insurance
Supplemental Insurance
Group Life Census Worksheet
Group Health Census Worksheet
Associations and Not-For-Profit
Applicant Information
* Required
Complete Business Name
*
Mailing Address/Street
City/State/Zip
Location Address/Street (if different from mailing)
City/State/Zip
Primary Contact Name
*
Contact Title
Phone Number
*
Fax Number
Email Address
*
Web Site Address
Type of Entity (e.g., Sole Proprietor, Corporation, Partnership, LLC)
Federal ID Number
Type of Business
(Describe typical services performed, customers served, products provided, etc.)
Do you set standards or provide any certifications?
Yes
No
Do you utilize volunteers? In what function, how many and how often?
Do you have any foundations or for-profit ventures? Are these operating under another separate entity name?
Please describe operations and relationship to the main organization
Years In Business
If New Venture, prior experience
Do you work or sell product overseas?
Yes
No
Do you have a board of directors?
Yes
No
Describe special events you hold
(annual conference, fundrasing activities, etc.)
Do any of these events generate a large amount of income for your organization that, if cancelled, would cause a significant loss of money in unreimbursable expenses?
If this applies to you, please describe
General Underwriting Questions
Was the Applicant created by, or now controlled by a governmental agency?
Accreditation Programs
Certification Programs
Development/Administration of Ethics Codes
Member Peer Review/Disciplinary Actions
Sponsorship of Insurance Programs
Standard Setting
Own or control any political action committees
Medical treatment at a non-residential facility, residential facility, or third-party medical services
Counseling or rehabilitation services
Fund own research and development
Transportation services for others
Social media, including blogging or bulletin-board-posting by the public
Sponsorship or organization of special events
Publishing, including periodicals, industry resource materials, research papers or other publications
If yes to any of the above, please provide details:
Current Insurance Information
Current Insurance Carrier (Name of Insurance Company)
How Long Insured
Date(s) Policy(s) Expire
Date Format: MM slash DD slash YYYY
Reason for Seeking New Carrier
Location / Building Information
Construction
Make a selection
Frame
Masonry
Non-Combustible
Fire Resistive
Metal
# of Stories
Year Built (approx.)
If over 30 years old, years of updating for
Wiring
Heating
Plumbing
Roof
Square Footage
Owner?
Yes
No
Tenant?
Yes
No
Alarms?
Burglar
Fire
Local
Central Station
Sprinklers?
Yes
No
Coverage/Rating Basis Information
Property
Replacement Value of Contents ($)
Should include Leasehold Improvements(may also be included in building so obtain a breakdown), Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, Property of Others
Replacement Value of Building, if applicable ($)
Replacement Value of Computer Hardware ($)
Valuable Papers ($)
Accounts Receivable ($)
Other property or equipment (specify what) ($)
Business Property Used/Transported/Stored Off-Premises ($)
Exterior Sign?
Yes
No
Exterior Glass?
Yes
No
Business Income ($)
General Liability
Each Occurrence Limit Desired ($)
Estimated Annual Gross Receipts ($)
Estimated Annual Total Payroll ($)
Number of Full Time Employees
Number of Part Time Employees
Do you use sub-contractors?
Yes
No
If yes, for what purposes?
Do you require sub-contractors to carry insurance and do you obtain certificates of insurance?
Yes
No
Worker's Compensation by State
State
Classification/Duties
Est. Annual Payroll ($)
Number of Employees
Owner/Officer Information
Name
Title
Duties
Incl/Excl
Automobile
Comprehensive Deductible ($)
Collision Deductible
Rented Vehicles used or Employee Vehicles Used in Business?
Yes
No
If yes, number of rental car days/year
If non-owned, how many employees drive their cars frequently for company business
If any key employees have company vehicles and do not buy a personal auto policy for their protection while driving for personal use (Drive Other Car Coverage ), list their names
Owned Vehicle Schedule
NOTE: You may complete with Vehicles and Drivers below, or fax us your list at 301-417-0040
YEAR
MAKE / MODEL
COST NEW
GARAGING CITY/STATE
RADIUS
USE in YEARS
Drivers Schedule (if you own vehicles)
(List all employees who drive any vehicle on company business)
NAME
DATE OF BIRTH
DRIVERS LIC #
STATE
ACCIDENTS/VIOLATIONS WITHIN LAST 3 YEARS
Prior Claim/Loss Information
Have you had any prior claims or losses?
Yes
No
IMPORTANT: IF YOU ANSWERED YES ABOVE, PLEASE CALL YOUR CURRENT AGENT AND REQUEST A COPY OF YOUR CLAIMS HISTORY (OR “LOSS RUNS”) FOR THE LAST THREE YEARS FOR ALL OF YOUR POLICIES
Other Optional Coverage to Consider
Do you need coverage for trips or work outside the United States?
Yes
No
Would you like an optional Umbrella Quote?
Yes
No
Would you like an Employee Benefits Quote (health, life, disability, long-term care)?
Yes
No
Would you like a Directors and Officers Liability Quote?
Yes
No
Interested in Any Other Coverage Not Shown Above?
Tweet
Share
Share
0
Shares