Business Insurance Form Please enable JavaScript in your browser to complete this form. – Step 1 of 6Business Name *Business Entity Type *LLCS-CorpC-CorpSole ProprietorshipBusiness Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBusiness Mailing AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *EIN NumberOwner(s)/Contact Name *Birthdate *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Birthdate MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Start date of business *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Number of year Business has been continually insured *If currently insured, What is the name of current insurance company?Does the owner(s) have over 3 years of experience doing the work you are requesting insurance? *If yes, what experience? Any certificates?Website / URLNumber of claims in the past 5 year? If yes, explain.Describe Business Operations *NextBusiness Liability InformationThis type of coverage can provide reimbursement for the resulting medical, repair and legal expenses if your business is held liable for injuring someone or damaging their property. For example, if a customer slips and injures themselves on your property, business liability insurance can help pay for any medical costs or lawsuits that may arise from the incident. Such a policy can also be supplemented with additional coverage endorsements—including fire legal liability and employment-related practices liability—based on your business’s unique risks and exposures.Liability Coverage *$500,000$1,000,000$2,000,000$4,000,000>$4,000,000For example, if a customer enters your flower shop, slips on your wet floor and breaks their leg, your general liability insurance can help cover the cost of their medical bills. General liability insurance does not cover your business’s employees.Annual Gross Income Or estimate income for a new businessGross income is the total revenue derived from sales of goods and services in a specified period.Annual Payroll now or in the future if new business *If current business, What is your premium amount?Do you need any specific endorsements? These are just a few, there are more depending on your business. * Additional Insured- Designated person Or OrganizationAdditional Insured-owners, lessess or contractors – completed operationsAdditional Insured Primary & Non-ContributoryWaiver Of Transfer Of Rights Of Recovery Against Others To Us FormIf having more than one additional insured, recommend having a blanket for additional insureds.Any chemicals or anything else we should know about?If you have a current business liability page and endorsements, please upload Click or drag a file to this area to upload. Property Information“This form of coverage can help protect your business’s building, as well as any commercial property surrounding the building and the contents within. These assets may include fencing, signage, furniture, equipment and inventory. If a covered event—such as a fire, burst pipe, storm damage or vandalism—damages or destroys your business’s building or its contents, commercial property insurance can recoup the cost of rebuilding, repairing or replacing the property. Commercial property insurance policies typically utilize one of the following valuation methods: Replacement cost coverage pays for the cost of rebuilding, repairing or replacing your business’s property as new (with similar materials and quality), without any deduction for depreciation. Actual cash value coverage reimburses your business for the cost of replacing the damaged or destroyed property, based on the depreciated value of the building or contents prior to the incident.”Do you own or rent the building for the business? *Year building was built and structure type ex. 1 storyHas the roof or heating been update? If yes, when?Square feet that you use vs the buildingBusiness personal property valueBusiness personal property (BPP) insurance offers financial protection for the repair or replacement of your lost, damaged, or stolen business property. It covers things like computers, furniture, and inventories.Are you interested in Cyber Coverage?YesNoMaybeThis type of coverage can help your business recoup expenses associated with a cyberattack or data breach. These costs may include legal fees that result from the breach, expenses related to informing customers of the incident and investigating the cause of attack, and the cost of recovering lost data or repairing damaged technology systems.Loss Runs, if you have previous insurance Click or drag a file to this area to upload. PreviousNextPayroll BreakdownOwner(s)- How many? Are the Owner(s) excluded from payroll?Full-Time Employees- Total Annual PayrollFull-Time Employees-Job DescriptionPart-Time Employees- How many?Part-Time Employees- Total Annual PayrollPart-Time Employees- Job DescriptionPreviousNextBusiness auto InformationThis type of coverage can provide protection for the vehicles your business uses to conduct its operations—including cars, trucks, vans and more. Commercial auto insurance typically includes three forms of coverage: Auto liability coverage can cover medical expenses and legal costs in the event that you or an employee causes an accident that injures another person or damages their property.Current Business auto policy number and termLiability Limits *300,000500,0001,000,0001,000,000+Comprehensive and Collison deductibles500/5001000/1000Collision and comprehensive coverage can recoup the price of repairing your business’s vehicle(s) after an accident or other covered event.Do you want Towing and Roadside Service?YesNoThird ItemHow many driver's?Will the driver's be covered by Workers Compensation?If more than one driver, will need name, birthdate, driver's license number and if that have had any tickets or claims.How many vehicles? How many trailers?Any special tools or Excavator's? With values of eachIf more than one vehicle or trailer we will need year, make, model, vin # and value or you can send a list to help@insideinsurance.netDo any vehicles have a loan on them? If yes, we will need to know which vehicle or trailer and who the loan is with.Premium amountHow much coverage is needed? 1 Million2 Million3 Million4 Million5 MillionDo you need any specific endorsements? These are just a few, there are more depending on your business. * Additional Insured- Designated person Or OrganizationAdditional Insured-owners, lessess or contractors – completed operationsAdditional Insured Primary & Non-ContributoryWaiver Of Transfer Of Rights Of Recovery Against Others To Us FormIf having more than one additional insured, recommend having a blanket for additional insureds.Loss Runs, if you have previous insurance Click or drag a file to this area to upload. Upload Business Auto policy or a list of driver's and vehicle information Click or drag a file to this area to upload. PreviousNextWorkers Comp InformationWorkers’ compensation provides medical expenses, lost wages, and rehabilitation costs to employees who are injured or become ill “in the course and scope” of their job. It also pays death benefits to families of employees who are killed on the job.Current policy numberCurrent termUnemployment number, if applicableMod Factor, if you have oneCoverage Amount$500,000$1,000,000$2,000,000Claims Yes or No and if yes how many?If you have current insurance what is the payroll class name and codePremium amountDo you need any specific endorsements? These are just a few, there are more depending on your business. * Additional Insured- Designated person Or OrganizationAdditional Insured-owners, lessess or contractors – completed operationsAdditional Insured Primary & Non-ContributoryWaiver Of Transfer Of Rights Of Recovery Against Others To Us FormIf having more than one additional insured, recommend having a blanket for additional insureds.Upload Current Worker's Compensation policy Click or drag a file to this area to upload. PreviousNextCommercial UmbrellaEspecially useful in high-loss situations, an umbrella policy can act as an added layer of protection to your business’s liability policies. Such a policy can provide coverage when the cost of a claim exceeds your policy’s limit of liability. For example, if your business receives a $1.5 million general liability claim after a customer injures themselves on your property, but your general liability policy limit is only $1 million, an umbrella policy could help cover the remaining $500,000.How much coverage is needed?1 Million2 Million3 Million4 Million5 MillionIf you would like to provide any additional information.Submit
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