Please enable JavaScript in your browser to complete this form.Business Name *Your Name *Your Position *SelectShareholder/OwnerSenior ManagementResearch ManagerHR ManagerSupport Team MemberFederal Tax ID *00-0000000 - if no tax ID, please enter Social Security numberYour Phone *Your Email *Best Time to Contact You *SelectMorningAfternoonEveningWeekendPreferred Contact Method *SelectPhoneEmailTextBusiness Address *Describe What Your Business Does *Web AddressEntity Type *SelectS CorpC CorpLLCNon-ProfitSole-ProprietorshipPartnershipYears in Business *Select3 or Less4 or MoreNew VentureYears of Industry Experience *Select10+More than 3Less than 3Reason for Considering Change *SelectCost, Coverage, & ServiceStrictly PricePast Claim ActivityNew BusinessOther States or Foreign Operations *SelectNoYesContemplated in the Next YearPersonal Insurance Review *SelectYesNo, Thank YouGroup Health Insurance Review *SelectYesNo, Thank YouLife Insurance Review *SelectYesNo, Thank YouUpload Copy of Current PolicyAdditional ActionsClick to List a Secondary Contact PersonClick to Include Liability InsuranceClick to Include Property InsuranceClick to Include Workers' Comp.Click for Auto SectionClick for Loss HistorySecondary Contact's Name *Secondary Contact's Email *Secondary Contact's Phone *Liability InsuranceCurrent CarrierProposed Effective Date *Need by Date *Number of Full Time Employees *Number of Part Time Employees *Payroll Projections *Subcontractors Cost *Gross Sales/Receipts Projections *General Liability Limit Desired Select$1,000,000/$2,000,000$2,000,000/$4,000,000Hired & Non Owned Auto Liability DesiredSelectYesNoFire Legal Damage to Property Limit DesiredSelect$100,000$300,000$500,000$1,000,000Professional Liability E&O Limit DesiredSelect1/11/22/4N/ACyber Liability Limit DesiredSelect$25,000$50,000$100,000$250,000$500,000$1,000,000Options for Umbrella Limit DesiredSelect$1,000,000/$1,000,000$2,000,000/$2,000,000Is There an Immediate Need for Certificates of Insurance or Additional NeedsSelectNoYesProperty InsuranceCurrent Carrier NameProposed Effective Date *Need by Date *Approximate Age of Building *Select0 to 25 Years26+ YearsAge of Electric/Plumbing/Roof/HVAC *Select0 to 25 Years26+ YearsYears at this Location *Select1 to 5 Years6-10 Years11-15 Years16-20 Years20+ YearsBusiness Personal Property (Business Equipment & Inventory) Limit DesiredMobile Equipment Coverage Limit DesiredTenant Improvements and Betterments Limit DesiredBuilding Insurance Limit DesiredLoss of Income or Rental Income Limit DesiredCrime Insurance Limit DesiredEarthquake and Flood Coverage Limit DesiredProperty in Transit Coverage Limit DesiredOtherWorkers CompensationCurrent CarrierDesired Effective Date *Need By Date *Include or Exclude Owners for CoverageSelectIncludeExcludeEmployers Liability Limits DesiredSelect$100,000/$100,000/$100,000$100,000/$500,000/$100,000$1,000,000/$1,000,000/$1,000,000$2,000,000/$2,000,000/$2,000,000Employee ClassificationNumber of EmployeesProjected PayrollEmployee Classification Number of EmployeesProjected PayrollEmployee ClassificationNumber of EmployeesProjected Payroll# of OwnersAuto InsuranceCurrent CarrierProposed Effective Date *Need by Date *Number of VehiclesNumber of DriversCombined Single Limit DesiredSelect$1,000,000 $2,000,000 Uninsured/Underinsured Motorist Limit DesiredSelect$1,000,000 $2,000,000 Medical Payments Coverage Limit DesiredSelect$1,000$5,000$10,000NoneUpload Vehicle Schedule and Driver ListLoss History Have There Been Any Losses in The Past 5 Years?SelectYesNoIf Yes, Please ExplainIf You Have Had Losses in Past 5 Years, Please Upload Loss RunsNameSubmit
