COMMERCIAL INSURANCE APPLICATION

APPLICANT INFORMATION SECTION

LINES OF BUSINESS

INDICATE LINES OF BUSINESS *

BOILER & MACHINERY

BUSINES AUTO

BUSINESS OWNERS

COMMERCIAL GENERAL LIABILITY

COMMERCIAL INLAND MARINE

COMMERCIAL PROPERTY

CRIME

CYBER AND PRIVACY

FIDUCIARY LIABILITY

GARAGE AND DEALERS

LIQUOR LIABILITY

MOTOR CARRIER

TRUCKERS

UMBRELLA

YACHT

PREMIUM *

$
$
$
$
$
$
$
$
$
$

POLICY INFORMATION

PROPOSED EFF DATE *

APPLICANT INFORMATION

NAME (First Named Insured)

FEIN OR SOC SEC#

BUSINESS PHONE # *

Business Type

CORPORATION

JOINT VENTURE

NOT FOR PROFIT ORG

SUBCHAPTER S CORPORATION

INDIVIDUAL

LLC NO. OF MEMBERS

PARTNERSHIP

TRUST

Other

CONTACT INFORMATION

CONTACT TYPE:

CONTACT NAME

PHONE TYPE

HOME

BUS

CELL

PRIMARY PHONE #

INTEREST

OWNER

TENANT

DATE OF BIRTH

ANY AREA LEASED TO OTHERS?

YES

AREA

ANNUAL REVENUES:
OCCUPIED AREA
OPEN TO PUBLIC AREA
TOTAL BUILDING AREA
DESCRIPTION OF SERVICES

PREMISES INFORMATION

LOC #
BLD #
STREET
CITY
STATE
COUNTY
ZIP

# OF EMPLOYEES

# FULL TIME EMPL
# PART TIME EMPL

NATURE OF BUSINESS

APARTMENTS

CONTRACTOR

MANUFACTURING

RESTUARANT

SERVICE

CONDOMINIUMS

INSTITUTIONAL

OFFICE

RETAIL

WHOLESALE

Description of Primary Operations

General Information
EXPLAIN ALL "YES" RESPONSES

1a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY

PARENT COMPANY

RELATIONSHIP DESCRIPTION

% OWNED

Y/N?

Yes
No
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1b. DOES THE APPLICANT HAVE ANY SUBSIDARIES

SUBSIDIARY COMPANY NAME

RELATIONSHIP DESCRIPTION

% OWNED

Y/N?

YES
NO
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2. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OR OPERATIONS? (Missouri Applicants - Do not answer this question) *

NON-PAYMENT

NON-RENEWAL

AGENT NO LONGER REPRESENTS CARRIER

UNDERWRITING

CONDITION CORRECTED (Describe):

Y/N

YES
NO
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3. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?

Y/N?

Yes
No
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4.DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY? (In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment).

Y/N?

Yes
No
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5. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS?

OCCUR DATE

EXPLANATION

RESOLVE DATE

RESOLUTION

Y/N?

Option 1
Option 2
Option 3
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6. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?

OCCUR DATE

EXPLANATION

RESOLVE DATE

RESOLUTION

Y/N?

Option 1
Option 2
Option 3
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PRIOR CARRIER INFORMATION

GENERAL LIABILITY

YEAR
CARRIER
POLICY NUMBER
PREMIUM
EFFECTIVE DATE
EXPIRATION DATE

AUTOMOBILE

YEAR
CARRIER
POLICY NUMBER
PREMIUM
EFFECTIVE DATE
EXPIRATION DATE

PROPERTY

YEAR
CARRIER
POLICY NUMBER
PREMIUM
EFFECTIVE DATE
EXPIRATION DATE

OTHER

YEAR
CARRIER
POLICY NUMBER
PREMIUM
EFFECTIVE DATE
EXPIRATION DATE

LOSS HISTORY

ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE LAST YEARS

TOTAL LOSSES

DATE OF OCCURRENCE

LINE

TYPE / DESCRIPTION OF OCCURRENCE OR CLAIM

DATE OF CLAIM

AMOUNT PAID

AMOUNT RESERVED

SUBROGATION

Yes
No
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CLAIM OPEN

Yes
No
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