Step 1 of 6 16% Named Insured - Entity:*DBA ( Business Name )*Address Line 1*Zip Code*City*StateSELECTALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CALIFORNIASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMINGINTERNATIONALState*Phone*Email* Contact Person* Fed Tax ID #:*Web-Site Address:Date Business StartedMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Years Experience in Business:Business Organization:SelectIndividualPartnershipCorporationLLCNon-ProfitOther - ExplainWhat Date Would You Like Your New Policy To Start?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Requested Effective Date: For New PolicyCurrent Insurance Carrier: Policy Number Annual Payroll:*Note: Annual Gross Sales. Do not include business owner or corporate officer’s salary/payroll.Number of Employees: Full Time*Select123567891010-2020-3030-40Number of Employees: Part Time*Select123567891010-2020-3030-40Any losses in the last three years?* Yes No (If Yes, provide complete Lost History Runs) Building Contents Coverage Limit:*Building Deductible:Please Select$250$500$1000Contents Coverage Limit:Please Select$5,000$10,000$15,000$20,000$25,000$30,000$40,000$50,000$100,000$200,000$300,000$400,000$500,001,000,0002,000,0005,000,000 or moreContents Deductible:Please Select$250$500$1000Construction Type:SelectFrame WoodFrame BrickJoisted MasonryOtherSprinkler System Yes No Number of Stories:Select12345Number of Basements:Select123Bldg Sq. Footage:Year The Building Was BuiltMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Year The Building Was Built:Sq. Footage Occupied:Burglar Alarm Type:SelectCentral StationLocalFire Protection:SelectCentral StationLocal Interest: Are You The Owner or TenantSelectOwnerTenantHAS THERE BEEN ANY RECENT BUILDING IMPROVEMENTS SELECT ALL THAT APPLY Wiring Heating Plumbing Roofing How much coverage are you looking for?General Liability Limits:Please Select$ 300,000 occurrence / $ 600,000 aggregate$ 500,000 occurrence / $1,000,000 aggregate$1,000,000 occurrence / $2,000,000 aggregate$2,000,000 occurrence / $4,000,000 aggregate$5,000,000 or greaterDo You Need Liquor Liability? Yes No Liquor License NumberLiquor Liability Annual Gross SalesLiquor Only:Internet Sales Is What Percentage Of Your Business?Please Select10 %15 %20 %30 %40 %50 %60 %70 %80 %90 %OtherVERIFICATION IF SOMEONE REFERRED YOU PLEASE ENTER THEIR NAME. IF NO ONE REFERRED YOU PLEASE ENTER HOW YOU HEARD ABOUT THE SITE Please enter any two digits*
