Business Insurance Inquiry

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GENERAL LIABILITY

Preferred Agent(Required)

Do you have a preferred agent you would like to work with?

Email Address(Required)

Your Name(Required)

Full Name of Business Entity(Required)

Type of Entity – Inc, LLC, Not-for-Profit:

Name, e-mail & contact phone number for officers and/or members. Include Support staff or business manager as well if necessary:

Business Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Location Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Tax-Payer ID # :

Year Entity Established:

Detailed Description of operations (please be specific):

Estimated Gross Annual Receipts:

Employees, Workman’s Compensation, & Sub Contractors

Number of Employees:

Description of their duties such as clerical, labor, technician, etc.

Estimated Annual Payroll for each category:

Sub-Contractors

Do your sub-contractors have the same liability limits as your General Liability?

Yes

Do your sub-contractors have Commercial Auto Liability Limits of $1M ?

Yes

Do your sub-contractors have Workman’s Compensation Coverage?

Yes

Do they provide you with a Certificate of Insurance and name your firm as Additional Insureds?

Yes

If using Sub-Contractors please provide a copy of your sub-contractor agreement.

Accepted file types: jpg, pdf, jpeg, png, doc, docx, pages, Max. file size: 50 MB.

Commercial Auto

Please provide a list of Power Units (Vehicles) with year, make & VIN, as well as all drivers to include full name, date of birth, driver’s license number and state of issue.

Accepted file types: jpg, pdf, jpeg, png, doc, docx, pages, Max. file size: 50 MB.

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Driving to Mexico?

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GENERAL LIABILITY

Employees, Workman’s Compensation, & Sub Contractors

Sub-Contractors

Commercial Auto

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