Get A Quote

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Name of Applicant (required)

Contact Email (required)

Phone Number

FEIN number (required)

Brief Description of operations (required)

Renewal Date (required)

Total Estimated Annual Payroll (required)

Total Estimated Annual Sales (required)

Years of Experience in Industry (required)

Radius of Travel (required)

Any prior insurance coverage for General Liability, Auto, Property, Equipment or Workers Compensation Coverage?
Yes No 

If yes, please attach Declarations Pages & any other related materials(audits, endorsements, exclusions, forms) pertaining to your insurance policies.

Do you have a current copy of your Loss history (claims reports) for current and previous 4 policy years?
Yes No 

If yes, please attach. If not, the agent whom bound the coverage can recover all reports related to your account and send to you directly.

Do you use sub contracted work? What is your cost of sub-contracting? Do you require that they carry insurance?
Yes No 

If yes, Please attachment sample copy of sub-contracting agreement.

Do you have a work on hand report (work in progress report) on file?
Yes No 

If yes please attach

Do you have a current copy of income statement and balance sheet?
Yes No 

If yes, please attach.

Is there a safety program in place?
Yes No 

If so, please attach.

Please briefly describe safety program and related meetings and activities undertaken by the company (required)

Do you have current copy of drivers list by name, drivers license number, and date of birth?
Yes No 

If so, please attach.

Do you have a current list of auto list by make, model, year, and VIN number?
Yes No 

If so, please attach.

Is there a drug testing program for all employees?
Yes No 

Are MVRs checked to ensure that all company employees are valid drivers whom are listed under your commercial auto insurance policy?
Yes No