Small Business Property & Casualty Application

LOGGED IN AS:

Small Business Property & Casualty Application

PLEASE NOTE: You are not able to save your progress on this application.
If you have started it please complete it and press 'SUBMIT APPLICATION'.


AGENCY INFORMATION:


Address:


,  
County:
Phone: ( ) -
Fax: ( ) -

* = Required
Contact Person *

Phone *
() - -
Fax
() - -
Email *

APPLICANT INFORMATION:

DBA (or Other Name if no DBA) *

Other Name

Mailing Address 1 *

Mailing Address 2

City, State Zip *
,  
County *
Business Description *

Entity Type *
 Individual
 Corporation
 Partnership
 Joint Venture
 Other
Experience *
Year Business Started
Total # Years Experience
Prior Experience Was As *
 Owner
 Other

PREMISES/LOCATIONS:

Location #1
Street *

City, State Zip *
,  

Add Another Location

Location #2
Street

City, State Zip
,  

Add Another Location

Location #3
Street

City, State Zip
,  

Add Another Location

Location #4
Street

City, State Zip
,  




LINES OF BUSINESS: *

 General Liability
 Property

General Liability
Proposed EFF Date (MM/DD/YYYY)

Proposed EXP Date (MM/DD/YYYY)

Target Premium

Property
Proposed EFF Date (MM/DD/YYYY)

Proposed EXP Date (MM/DD/YYYY)

Target Premium


PRIOR CARRIER INFORMATION:

General Liability
Current Carrier

Premium

Incumbent Broker?
 YES
 NO
Property
Current Carrier

Premium

Incumbent Broker?
 YES
 NO

LOSS HISTORY:

 Check if No Losses or No Loss History
General Liability
Time Period
TO:
Expiring Carrier

Incurred Amount

# Losses
 Paid/Rsrv
 CWP
 Exp Only
Property
Time Period
TO:
Expiring Carrier
Incurred Amount

# Losses
 Paid/Rsrv
 CWP
 Exp Only

GENERAL LIABILITY

General Liability Limits

General Aggregate *

Prod/CO Aggregate *

Personal & Adv Inj *

Deductible

Per Occurence *

Fire Damage Legal *

Medical Payments *


 BI     PD     BIPD
Coverage Form
 Occurence     Claims made (Retro date:)
Optional Coverages
 Additional Insured    
 Waiver of Subrogation
 Employer's Liab
 Employee Benefit's Liab
 Stop Gap Coverage

ADDITIONAL INSUREDS:

Insured #1 Name *

Street *

City, State Zip *
,   Interest *


Add Another Insured

Insured #2 Name 

Street 

City, State Zip 
,   Interest 


Add Another Insured

Insured #3 Name 

Street 

City, State Zip 
,   Interest 


Add Another Insured

Insured #4 Name 

Street 

City, State Zip 
,   Interest 





General Liability Risk Schedule

Loc #1
Description *

Prem Basis *
Exposure *


Add Another Risk Schedule

Loc #2
Description 

Prem Basis 
Exposure 


Add Another Risk Schedule

Loc #3
Description 

Prem Basis 
Exposure 


Add Another Risk Schedule

Loc #4
Description 

Prem Basis 
Exposure 





PROPERTY:

Location #1

Description *

Ded *

Co Ins *

Operations *

Constr *
Wiring Update Year *

Roofing Update Year *

Plumbing Update Year *

Heating Update Year *

Protection Class *

Year Built *

Area *



Building

Conv

Limit

Valuation


Personal Property

Conv

Limit

Valuation


Business Income

Conv

Limit

Include Extra Expense
Indemnity

Co Ins


Extra Expense

Conv

Limit

Limits


Location #2

Description 

Ded 

Co Ins 

Operations 

Constr 
Wiring Update Year 

Roofing Update Year 

Plumbing Update Year 

Heating Update Year 

Protection Class 

Year Built 

Area 



Building

Conv

Limit

Valuation


Personal Property

Conv

Limit

Valuation


Business Income

Conv

Limit

Include Extra Expense
Indemnity

Co Ins


Extra Expense

Conv

Limit

Limits


Location #3

Description 

Ded 

Co Ins 

Operations 

Constr 
Wiring Update Year 

Roofing Update Year 

Plumbing Update Year 

Heating Update Year 

Protection Class 

Year Built 

Area 



Building

Conv

Limit

Valuation


Personal Property

Conv

Limit

Valuation


Business Income

Conv

Limit

Include Extra Expense
Indemnity

Co Ins


Extra Expense

Conv

Limit

Limits


Location #4

Description