Business Insurance

BUSINESS NAME

Doing Business As (Optional)

Business Website (Optional)

FIRST NAME

MIDDLE NAME INITIAL

LAST NAME

Your Email

Date of Birth

What is the physical address of your primary business location?

Use business address as my mailing address

Yes No

Address Line 2

Zip Code

State

What Type Of Work Does Your Business Do?

What is the total number of business and residential units within the building you operate out of?

Estimated annual rental income:

Do you have any employees?

Yes No

Is It Just The Owners?

Yes No

How many employees do you have??

How many property or liability claims have you had in the past 3 years?

Where does your business operate?

Do clients visit your home as part of your business?

Yes Clients Visit My Home No Clients Don't Visit My Home

When was your last policy in effect?

Does your business own or lease any of the following?

This policy provides General Liability for incidents such as slips and falls at your business, but it does not cover your professional services. You can purchase a separate policy to cover Professional Liability. Do you acknowledge that this policy does not cover Professional Liability?

Yes

Is the building currently under construction or renovation, or planned to be during the next 12 months?

Yes No

Does your business use any vehicles that it does not own?

Yes No

Do you sell any cannabis products other than hemp-derived CBD?

Yes No

Are you required to name a third party as an additional insured or loss payee on your policy?

Yes No

How many stories is your building?

In what year was your building originally built?

When do you want your policy to start?

When did you start your business?

How is your business structured?

Does your business own or operate out of more than one building?

Yes No

What is the total square footage of your building?

Was the roof updated in the last 25 years?

Yes No

Which of the following best describes how your building is constructed?

Brick, cement, or concrete block walls with a wood frame roof, usually covered by shingles or clay. (Joisted Masonry) Wood frame exterior walls, normally covered by siding or brick veneer. (Frame) Brick, cement, or concrete block walls with a steel roof. (Masonry Non-Combustible) Metal building with a steel frame, may have some masonry materials. (Non-Combustible) Walls and roof are concrete materials (Fire Resistive)

Do you have any of the following protective devices?

Do you currently have a property or general liability policy in effect?

Yes No

Do you need to add a bank or lender to your policy?

Yes No

How many other people or organizations do you need to add?

Do you need to add vendors to your policy?

Yes No

Do you need to add a grantor of franchise to your policy?

Yes No

Do you need to add an equipment lessor on your policy?

Yes No

Do you need to add other people or organizations to your policy as an additional insured or loss payee?

Yes No

Are you required to name a loss payee on your policy?

Yes No

Damage To Premises Rented To You

Medical Expenses - Each Person:

Building Coverage

Property Deductible

Include Terrorism Coverage?

Yes No

BUSINESS INSURANCE