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1. Requested Effective Date:
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2. Name of Present Carrier:
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3. Applicant Information:
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Company Name:
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Contact Name
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Street Address
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State:
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City:
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Zip Code:
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4. Years in Business
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5. Federal Employer ID Number:
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6. Named Insured is:
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Other explaination
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7. Interest of the Insured:
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8. Describe any losses in the last three years at each location. Include date, type of
loss & amount paid: (This is for either Workers Comp and the Business Owners Policy
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9. Business Liability Limits of Insurance
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10. Limit of current Insurance:
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11. Building Value: Not applicable if tenant$
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12. Business Personal Property (Non Computer)
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13. Business Personal Property (Computer)
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14. Describe You Business
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15. Construction
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16. Code
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17. Protection Class
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18. Locations:
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Location 1
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Street Address
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State:
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City:
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Zip Code:
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Categories, Duties, Classifications:
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No. of Employees:
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Estimated Annual Remuneration:
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Location 2 (If necessary)
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Street Address
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City:
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State:
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Zip Code:
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Categories, Duties, Classifications:
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No. of Employees:
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Estimated Annual Remuneration:
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Location 3 (If necessary)
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Street Address
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City:
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State:
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Zip Code:
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Categories, Duties, Classifications:
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No. of Employees:
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Estimated Annual Remuneration:
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The signer of this application, authorized and acting on behalf
of all Insureds declares that all statements and information
provided by the Insureds is true, complete and accurate. It is
agreed that this application is the basis of and becomes a part
of the policy, should a policy be issued.
The signing of this application does not require the signer to
purchase insurance, nor does the review of this application
require the Insurer to issue a policy.
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Signed
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Title
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Date
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