General Information
Named Insured
Corp, LLC, sole prop, partnership?
Mailing Address
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Contact Name
Phone Nuumber
Number of Years in Business
Federal Employee Identification Number
Present Carrier(s)
Present Broker(s)
Business Description (please include a broad narrative of your operations)
Web Address
Property Underwriting: (please complete per location)
Building Age
If the building is more than 25 years old, please describe any improvements to the building (electrical, roof, etc).
Number of Stories
Square Footage (total building)
Square Footage (occupied by insured)
If the building is not fully occupied by insured, describe other tenant occupancies (office, mfg, warehouse, etc)
Is the building protected by a fire sprinkler system?
Does the unit have a central station alarm?
If so, what company services the c/s alarm?
Does the building have a basement?
What is the total replacement cost of business personal property (BPP is defined as furniture, fixtures, tenant improvements, stock, and inventory?
What percentage of the BPP is permanently attached to the building?
Do you have any property of “others” (customers, etc.) in your care, custody and control? If so, what is the replacement cost value of this property?
Is any of your BPP perishable? If so, what is the replacement cost of this property?
What is the replacement cost value of your computer hardware and software?
What is the maximum amount of money and securities on the premises?
Maximum amount of property off premises (this includes in transit)
Commercial General Liability:
Estimated annual receipts
What percentage of the annual receipts is from foreign jurisdictions (away from US, US territories and Canada)?
Number of employees
Do you use a standard contract with your clients / vendors? If so, please attach.
Gross annual payroll
What percentage of your work is subcontracted?
What type of work is subcontracted?
Do you utilize a subcontract agreement that requires them to name you as additional insured?
What percentage of the payroll is clerical / administration only?
Do you currently carry professional liability coverage? (PL covers economic loss by a third party based on your failure to meet a professional standard of care)
If so, name carrier, expiration date and limit
Commercial Autos:
Any corporately registered autos?
If so, provide make, model, VIN, cost new, garaging address and driver info (name and license number)
How many rental cars a year are rented by named insured?
Workers Compensation:
Current Carrier
Expiration Date
Experience Modification
Provide estimated annual payroll by class code
List all officers of corporation, titles, and percentages owned
Do you provide group medical coverage for your employees? Who is the provider?
What percentage of the employees participate in the group medical plan?
Do any employees travel overseas? If so, how many trips per year.
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Narrative of Operations
Product Brochures (if applicable)
Copy of Lease(s)
Five year hard copy loss runs on all policies (valuation date within 90 days of policy expiration)
Sample contracts