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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
Professional Cleaning Services Program
Professional Cleaning – Commercial
General Information
Date Form Completed
Date Format: MM slash DD slash YYYY
Person Completing Form
Franchise Affiliation, if any
Business Name (incl Corp and T/A names)
Contact Person
Title
Mailing Address
Location Address
Phone
Fax
Email
Entity Type (Corp, Sole Prop, LLC, etc)
Date business started
Federal ID #
Current Insurance Carrier(s)
How Long with Carrier(s)?
Coverage Expiration Date
Date Format: MM slash DD slash YYYY
Do all policies expire on same date? If not, provide all dates
Please list all states in which you do business
# of Clients/Contracts
* PLEASE ATTACH COPIES OF YOUR CURRENT POLICY DECLARATIONS PAGES FOR MOST ACCURATE QUOTE *
Policy Limits | PROPERTY
Building
► Office Contents Replacement Value
Business Income (if over $50,000)
Valuable Papers (if over $25,000)
Accounts Receivable (if over $25,000)
Exterior Sign
Building Glass (measurements)
Other Property (Describe / Value)
Unscheduled Mobile Equipment Limit (max $1,000 per item)
Scheduled Mobile Equipment (for individual items exceeding $1,000): PLEASE ATTACH SCHEDULE
► Contents may include, but is not limited to: Leasehold Improvements, Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, and Property of Others in Your Care. Please consult your lease requirements when choosing the coverage and limits for this location.
Policy Limits | CRIME
Employee Dishonesty (if over $25,000)
Money & Securities (if over $10,000)
401(k) Plan? Name of Plan
Policy Limits | GENERAL LIABILITY
General Aggregate Limit
Each Occurrence Limit
Fire Legal Liability Limit
Medical Payments Limit
Property Damage Deductible (if over $500)
Employee Benefits Liability (if group benefits provided)
WORKERS COMPENSATION | OWNERS | List below all owners of the business, whether active or inactive.
Owner/Officer Name
Title
% of Ownership
Duties (or indicate if inactive)
Annual Payroll/Salary
Include or Exclude?
WORKERS COMPENSATION | List below payroll for all employees EXCEPT OWNERS
Janitorial Services – Labor
Estimated Annual Payroll (do not include owners here)
# FT Employees
# PT Employees
State
Employers Liability Limit (if other than 100,000 / 500,000 / 100,000)
Office – Inside
Estimated Annual Payroll (do not include owners here)
# FT Employees
# PT Employees
State
Employers Liability Limit (if other than 100,000 / 500,000 / 100,000)
Sales – Outside
Estimated Annual Payroll (do not include owners here)
# FT Employees
# PT Employees
State
Employers Liability Limit (if other than 100,000 / 500,000 / 100,000)
Policy Limits – AUTOMOBILE
Auto Liability (Combined Single or Split Limits)
Uninsured / Underinsured Motorist Limit(s)
Medical Payments
Personal Injury Protection
Comp Deductible
Collision Deductible
Towing & Labor (for private passenger vehicles)
Rental Reimbursement
If any owners / key employers have their personal vehicles on policy, please give their names and names of their spouses
Policy Limits – UMBRELLA
Umbrella Liability Limit (if other than $1,000,000)
PROPERTY – Underwriting Questions
Type of building you occupy (office, retail strip mall, industrial, etc.)
Owner or Tenant?
# of Stories
Construction (Frame, Masonry, Noncombustible, Fire Resistive, etc)
Sq Ftg You Occupy
Approx Yr Built
If bldg over 30 yrs old, Year(s) Updated for Wiring, Heating, Plumbing, Roof
GENERAL LIABILITY – Underwriting Questions
Estimated Annual Receipts
Annual Receipts for Prior Year
Annual Amt Paid to Subcontractors
Do Subs provide Certificates with limits at least equal to yours?
Yes
No
Is a formal safety program in operation?
Yes
No
Any exposure to flammables, explosives, chemicals?
Yes
No
Do you install, service, or demonstrate products?
Yes
No
Do you provide guarantee, warranty, or hold harmless?
Yes
No
Any exposure to radioactive / nuclear materials?
Yes
No
Any operations involving storing, treating, discharging, applying, disposing, or transporting of hazardous material?
Yes
No
Do you lease employees to or from other employers?
Yes
No
Have any crimes occurred or been attempted on your premises within the last three years?
Yes
No
Is there a formal, written safety and security policy in effect for your location?
Yes
No
Does your promotional literature make any representations about the safety or security of the premises?
Yes
No
Do you install, service, or demonstrate products?
Yes
No
Explain all YES answers below
AUTOMOBILE – Underwriting Questions
Do over 50% of employees use their autos in the business?
Yes
No
Is there a vehicle maintenance program in operation?
Yes
No
Are any vehicles leased to others?
Yes
No
Any vehicles customized, altered or have special equipment?
Yes
No
Do operations involve transporting hazardous material?
Yes
No
Any vehicles used by family members? If so, identify below.
Yes
No
Do you obtain motor vehicle records for new drivers?
Yes
No
Do you have a specific driver recruiting method?
Yes
No
Any drivers with moving traffic violations?
Yes
No
Explain all YES answers below
WORKERS COMPENSATION – Underwriting Questions
Do you have an Experience Modification Factor?
Yes
No
If so, what is that factor and when is it effective?
Any work performed underground or above 15 feet?
Yes
No
Are you engaged in any other type of business?
Yes
No
Any group transportation provided?
Yes
No
Any seasonal employees?
Yes
No
Do employees travel out of state?
Yes
No
Are physicals required after offers of employment are made?
Yes
No
Are employee health plans provided?
Yes
No
Do any employees predominantly work at home?
Yes
No
Any prior coverage declined, cancelled or non‐renewed in the last 3 years?
Yes
No
Explain all YES answers below
UMBRELLA – Underwriting Questions
Is bridge, dam, or marine work performed?
Yes
No
Is contract or agreement made with customer? If so, attach copy
Yes
No
Do you own, rent, or otherwise use cranes or scaffolds?
Yes
No
Explain all YES answers below
ADDITIONAL REMARKS
VEHICLE SCHEDULE – Please complete the below or attach a separate schedule of your own
Year
Make / Model
Vehicle ID (Serial Number)
Original Cost New
Garaging City, State
** Titled/Leased in business name?
Yes
No
** For vehicles not titled/leased in the business name, please indicate the name of the titled owner or lessee for each vehicle:
DRIVER SCHEDULE – Please complete the below or attach a separate schedule of your own
Driver Name (as it appears on license)
Drivers License Number
State
Date of Birth
Date Format: MM slash DD slash YYYY
GENERAL UNDERWRITING QUESTIONS
Do employees work in pairs?
Yes
No
Are employees supervised on the job?
Yes
No
Are single‐person jobs limited to experienced staff?
Yes
No
Are periodic unannounced job site management checks performed?
Yes
No
Are written applications completed by all prospective employees?
Yes
No
Are references checked?
Yes
No
Does employment application ask about prior criminal acts?
Yes
No
Are criminal background checks performed on all employees?
Yes
No
Any bid or performance bonding needed?
Yes
No
DESCRIBE BELOW ANY LOSS CONTROL & SAFETY MEASURES IN PLACE TO AVOID EMPLOYEE INJURY, AUTO ACCIDENTS, AND CUSTOMER PROPERTY DAMAGE (driver training, loss prevention meetings, new hire training, etc.)
OTHER COVERAGE TO CONSIDER – Please type any comments or requests below
Do you need coverage for trips or work outside the United States?
Would you like an optional Umbrella Quote?
Would you like an Employee Benefits Quote (health, life, disability, long‐term care)?
Would you like an Employment Practices Liability Quote?
Interested in any other coverage not shown above?
Describe Other Coverage requests here:
PLEASE CONTACT YOUR CURRENT AGENT OR INSURANCE COMPANY FOR A CURRENTLY‐VALUED LISTING OF YOUR CLAIMS HISTORY (“LOSS RUNS”) FOR THE PAST 3 YEARS.
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