Commercial Insurance Program
Company Name :
Mailing Address :
Street Address :
City:
State:
Zip:
Email:
Phone # : Fax #: Policy Effective Date:
Current Annual Premium:
Current Insurance Company :
Policy # :
Property Coverage Building 1
Limit:
Construction Type of Building :
Square Footage of Building:
Contents:
Building 2 (optional)
Gross Business Income :
Contractor Tools off Premise :
Contractors Mobile Equipment:
Auto Service Employee Tools:
Computers & Data :
Crime Coverage
Employee Dishonesty :
Money & Securities :
Premises, Operations, Products, Completed Operation, etc.:
Liability Coverage Limit :
Annual Gross Receipts :
Number of Employees :
Contractors Annual Payroll (Do not include Clerical Payroll Owner's Payroll capped at $17,800 yr. All other Employees Payroll capped at $31,200 yr.)
Electrical:
Heating & Air :
Plumbing:
Painting:
Masonry:
Landscaping:
Flooring:
Sub-Contracted Receipts:
Garage
Auto Repair - # of Mechanics:
Restaurant
Area available to public :
Apartment Buildings
Number of Units:
Commercial Auto
Liability Limits :
Un-Insured motorists Limit:
Medical Payments:
Comprehensive Deductible :
Collision Deductible :
Add Vehicle
Model year :
Make:
VIN # :
Add Vehicle 2
Add Vehicle 3
Add Vehicle 4
Add Driver
Name:
Birthdate:
Drivers License # :
Description of Accidents / Citations :
Add Driver 2
Add Driver 3
Commercial Liability Umbrella - Limit: v
