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EP Token: Company Name

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When do you want your policy to start?*

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What kind of business do you operate?*

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Which type of insurance are you looking for?*

Check all that apply.

General Liability

Business Owners Policy

Commercial Auto

Garage & Dealers Policy

Workers Comp

Trucking

Professional Liability

Equipment Floater - Inland Marine

Property

Lessor's Risk

Commercial Umbrella

Cyber Liability

Crime Liability

Other

Other type of insurance*

How did you hear about us?*

Name of Referrer*

Referrer's Phone and/or Email

Other Referral

Business Information

Legal Business Name*

Building Owner's Name*

Entity Type*

DBA

FEIN

Website

Business Address*

Street Address City State Zipcode

Mailing Address*

Same as Business Address

Street Address City State Zipcode

Email*

Work Phone*

Year Business Started*

Years operating this business?*

Years experience in this field?*

Year Building Was Acquired*

Years Actively Leasing the Building

If less than 3 years experience, explain your prior experience and any Specialized Training or Certification*

Is this business affiliated with a franchise?

Yes

DOT#

MC#

Primary Business Contact

Primary Insured: Name*

First Last

Primary Insured: Date of Birth*

Month

Day

Year

Mobile Phone

Can we text you

By checking this box, you consent to receive text messages from Blackwell Insurance Agency Inc. at the mobile number provided regarding your insurance inquiries, quotes, and policy updates. Consent is not a condition of purchase. Message and data rates may apply. Message frequency varies. Reply HELP for help or STOP to cancel. View our Privacy Policy and Terms of Service

Additional Business Owners

If there are multiple owners of the business, enter their information below. Otherwise you may skip this section.

Additional Owners List

Owner Name	Company Role	Email	Phone	Actions

There are no Owners.

Maximum number of owners reached.

Type of Organization (NEMT)

Emergency

Non-Emergency (Ambulance)

Non-Emergency (Transport)

Volunteer

Individual

Partnership

Corporation

For-Profit

Non-Profit

C. Municipality (Fully describe interest, control, financial support):

D. Other (Please explain):

What states are you licensed or certified in? Please provide details of what your license/certification allows you to do:

Are you affiliated with any other entity?

Yes

Please describe the relationship.

Population of area served:

Radius of Operation (Miles):

Sales (If applicable): $

No. of Volunteer Members

No. of Paid Members

Service and Operations Information (NMET)

Type of service(s) you provide:

Wheelchair Transport

Ambulatory Transport

Stretcher/Litter Transport

Assisted Transport

Senior/Disabled Transport

Medical Appointments

Post-Surgery/Recovery Transport

Non-Emergency Ambulance

Other

Please specify other type(s) of service(s).

Please provide how many vehicles and staff you currently have for your NEMT services.

Wheelchair-accessible vans

Ambulatory vehicles

Stretcher-equipped vehicles

Drivers

Dispatchers/Coordinators

Attendants/Aides

Do you use subcontractors?

Yes

Do you transport prisoners or psychiatric patients?

Yes

Do all non-emergency transport drivers have current CPR or AED certification?

Yes

What is your current Auto Insurer?

Current Limits ($):

Please upload Vehicle Schedule.

Drop files here or

Max. file size: 20 MB.

Are there written procedures in place requiring the documentation of all incidents?

Yes

Do you have any of the following written procedures and training in place?

Please check all that apply.

Loading and unloading

Wheelchair locking and tie-down

Emergency/accident reporting procedures

HIPAA regulation and policies

Do you perform background checks on all employees that include criminal background checks, sex offender registry and references?

Yes

Have you had any incidents or claims brought against you for sexual molestation or any other allegation of misconduct?

Yes

If you are a volunteer fire department with paramedics, EMTs and First Responders, or an individual, please complete the following.

What type of entity do you provide services for?

What type of emergency services do you perform?

Do you have any supervisory duties?

Yes

Please describe

Are you a Nurse Practitioner, Advanced Practical Nurse or Physician's Assistant?

Yes

Vehicles

Are all vehicles garaged at the business address?*

Yes

Vehicles List

Year	Make	Model	VIN	Actions

There are no Vehicles.

Maximum number of vehicles reached.

Trailers

If you have a trailer(s) you want listed on your policy, enter their information below.

Trailers List

Trailer Type	Year	Make	Model	Actions

There are no Trailers.

Maximum number of trailers reached.

Primary Insured Driver Info

Primary Insured: Drivers License Number*

Primary Insured: Drivers License State*

Commercial License? (CDL)

Yes

Year CDL Issued

Additional Drivers

Do any of your drivers take the vehicle(s) home at night?*

Yes

Have all drivers had a valid U.S. driver's license for at least 2 years?*

Yes

Drivers List

Driver Name	Date of Birth	Drivers License #	Drivers License State	Hire Date	Actions

There are no Drivers.

Maximum number of drivers reached.

Do you use contract or occasional drivers not listed above?*

Yes

How many drivers used annually?*

Trucking Underwriting

Projected annual mileage*

Number of Trailers to insure

What coverages are you looking to have in place?*

Check all that apply

Auto Liability

Physical Damage

Cargo

General Liability

Bobtail

Non-Trucking Liability

Umbrella / Excess

Commercial Property / Premises

Occupational Accident

Workers Comp

Hired / Non-Owned Auto

What are the minimum years of CDL experience required for drivers?

What are the maximum Daily and Weekly driving hours for each driver?

How are drivers paid?*

Hourly

By Trip

By Mile

Other

Which of the following is part of your driver screening/hiring process?*

Employment Background Check

Criminal Background Check

MVR Review

Behavioral / Integrity Test

Pre-Employment Drug Test

Road Test

Pre-Employment Screening Program (PSP) report for FMCSA

Check all that apply

In the past 5 years have you, or any driver, been convicted of any of the following?

Check all that apply

Leaving the scene of an accident / hit and run

Felony conviction involving a motor vehicle

Driving while license suspended or revoked

DUI or DWI

Negligent Homicide

Unlawful use of vehicle

Speed contest or racing

Reckless Driving

Speeding 20mph+ over the limit

Name, conviction, date, and details

Are drivers covered by workers comp?*

Yes

Do you haul for hire?*

Yes

Do you Barter Hire or Lease any drivers or vehicles out for others to use?*

Yes

Which party provides primary auto liability coverage?*

My Business

Other Party's Business

Do you Barter Hire or Lease any drivers or vehicles to haul under your authority?*

Yes

Are owner-operators subject to the same hiring, training, and equipment maintenance standards as company drivers?*

Yes

On what basis are vehicles and drivers leased?*

Permanent

Temporary / Trip Basis

Do you require and get evidence that leased vehicles owners purchase non-trucking liability?*

We will need a copy of the lease agreement

Yes

Does your company allow any of the following practices?

Check all that apply

Deadheading

Trailer Spotting

Double and/or Triple Trailer Hauling

Team Driving

Slip Seat / Relay Drivers

Non-Employee Passengers

All drivers to bring vehicles home

Trucking Underwriting

Do you need Federal Filings*

Yes

Note: For Federal Filings, an MCS 90 Endorsement is needed too.

Do you need State Filings?*

Yes

State(s) and Permit #s*

Is any part of your operation seasonal?

Yes

Does vehicle(s) have an ELD installed?

Yes

ELD Provider

What state(s) does your business operate in?

What are the 3 largest cities you enter?

Does your business provide any of the following general services?*

Storage

Loading / Unloading

Packing / Crating

Rigging

Decking / Tarping / Blanket Wrapping Freight

Delivery / Installation Services

Garaging

Vehicle and Equipment Repair

Commercial or Residential Moving Services

Does your business generate revenue from any services other than trucking for hire?*

Yes

Please explain other revenue generated*

Have you ever changed your operating name?*

Yes

Do you operate under any other names currently?*

Yes

Do you operate as a subsidiary of another company?*

Yes

Have you purchased, sold, or applied for authority over the past 3 years?*

Yes

Have you ever lost, or had authority withdrawn, or have been/are under probation by any regulatory authority? (FHWA, PUC, etc.)*

Yes

Do you agree to report all newly hired operators?*

Yes

Do you agree to report all newly purchased or leased equipment?*

Yes

Business Information Continued

What is your total annual sales/revenue? (Gross)*

Percentage of gross revenue from inside U.S.A.?

Percentage of gross revenue from outside U.S.A.?

Percentage of gross revenue that comes from advertising revenue?

Do you have employee(s)?*

Yes

Owner payroll*

Number of employees*

Estimated annual payroll*

Do you lease your employees?*

Yes

Do you use any subcontractors? (1099s)*

Yes

Number of subcontractors*

Subcontractor annual payroll*

What type of work do your subs perform?*

Do you have a written contract with your subs requiring them to name your business as Additional Insured and show proof every year?*

Yes

Not yet

Are all subcontractors required to sing a hold harmless and indemnification agreement in your favor?*

Yes

Not yet

What is your annual rental income? (Gross)*

Number of Tenants*

Tenant Information*

Please list the tenant information below. Click the “+” icon to add additional rows as needed.

Tenant/Business Name

Sq. Ft. Occupied

Trades Information

Number of contractor licenses you currently hold

Do operations include installation, service, or repair?*

Yes

Do business services include cleaning construction sites including debris removal?*

Yes

Do you perform snow and/or ice removal?*

Yes

Do you remove snow from streets or highways?*

Yes

Do operations involve the use of a crane?*

Yes

Do operations involve excavation?*

Yes

Select the types of excavation you perform

General excavation or trenching

Blasting

Dredging

Swimming pool excavation

Wrecking or demolition

Percentage of work involving excavation*

Do you use OSHA approved trenching/blasting safeguards?*

Yes

Do you demolish whole buildings or structures?*

Yes

Do jobs involve or expose employees to the following?

Select all that apply

Asbestos removal or exposure

Disaster recovery work

Fire, water, mold damage restoration or remediation

Lead paint removal

Oil, gas, or wells

Licenses

Please provide information about any licenses you have obtained. If you have no licenses, you may skip this section.

Licenses Held

License Type

License Number

Have you operated or been licensed under any other name(s) during the past 10 years?*

Yes

Construction Work Information

Please provide a breakdown of work as:

General Contractor*

Subcontractor*

Developer*

Construction Manager*

Consultant Only

% Work Residential (New)*

% Work Residential (Remodel)*

% Work Commercial (New)*

% Work Commercial (Remodel)*

% Work Industrial (New)*

% Work Industrial (Remodel)*

If new residential construction work is being done, please indicate type(s) below.

% New Apartments*

% New Condo/Townhouses*

% New Custom Homes*

% New Tract Homes*

Any construction of the following?

Select all that apply

Airports

Nuclear Plants

Railroads

Stadiums

Subways

Any work performed above 4 stories in height?*

Yes

Maximum number of stories*

Any work performed below grade?*

Yes

Maximum depth (in Ft)*

Is scaffolding owned, rented, or erected?*

Yes

Are other contractors at the job site allowed to use such scaffolding?*

Yes

Any mobile equipment leased from others?*

Yes

Type of equipment leased*

Do you have a formal safety program in force?*

Yes

Do you have Workers Compensation coverage in force?*

Yes

Do any employees have any of the following:

Work under U.S. Longshoremen and Harborworkers Act

Work under Jones Maritime Act

Hold a Real Estate Agent License

Do you own any vacant land?*

Yes

Number of acres*

Do you plan to develop this property within the next policy term?*

Yes

Have you ever been involved in any construction defect claims?*

Yes

Do you participate in any owner-controlled insurance program (OCIP) or Wrap-Up insurance?*

Yes

Current or Recent Projects

Please provide up to 6 current or recent construction projects, cost of project and duration.

If you are a new business with no current or previous work history, you may skip this section.

Project Description

Cost of Project ($)

Duration

Architects, Engineers, Draftsmen

Is your firm controlled, owned by or associated with, or does your firm control or own any other firm, corporation or company?*

Yes

Is your firm engaged in any of the following?*

Select all that apply

Actual construction, fabrication, or erection

Responsible for construction means, methods, techniques, procedures, or job site safety

Design / Build Projects as Prime

Hiring contractors

The manufacture, sale, leasing, or distribution of any product, process or patented production process

The development, sale, or leasing of computer software to others

Real estate development

Professional Services

Please indicate percentage of professional services rendered in-house by applicant, by current percentage of billings. (Percentages to equal 100%)

% Acoustical Engineering

% Architecture

% Civil Engineering

% Construction Mgmt - Agency

% Construction Mgmt - At Risk

% Electrical Engineering

% Environmental Engineering

% Forensic/Expert Witness

% Geotechnical/Soils Engineering

% HVAC Engineering

% Interior Design

% Land Surveying

% Landscape Architecture

% Mechanical Engineering

% Process Engineering

% Structural Engineering

% Testing Lab

% Traffic Engineering

% Other

Please describe other Professional Services

Design / Build Services

Please provide Construction Values for the below. (Complete only if firm is doing Design/Build projects)

Design/Build Projects below not applicable

N/A

Construction Value:

Projected Fiscal Year

Construction Value:

Current Fiscal Year

Construction Value:

Immediate Past Fiscal Year

Projected Fiscal Year

Current Fiscal Year

Immediate Past Fiscal Year

Design/Construct (projected fiscal)

Design/Construct (current fiscal)

Design/Construct (immediate past fiscal)

Design Only (projected fiscal)

Design Only (current fiscal)

Design Only (immediate past fiscal)

Construction Only (projected fiscal)

Construction Only (current fiscal)

Construction Only (immediate past fiscal)

Scope of Services

Please provide percentages, total to equal 100%

Scope of services below not applicable

N/A

Feasibility studies, opinions, forensic, expert witness, or reports that will not result in construction.

Surveys, resulting in construction.

Design only with no construction phase services.

Design with responsibility for periodic observation during the construction phase to ensure design compliance.

Design with responsibility for wholly or partly supervising the contractor.

Construction phase services without responsibility for preparing the drawings and specifications.

Special Services

Please provide percentages, total need Not equal 100%.

Alternative Energy

Approval or signing of other than your own work product

Asbestos Related Services

Building/Home Inspections

Design of Scaffolding, Supporting, or Shoring

Environmental Audits or Assessments

Exterior Insulation and Finish (EIFS)

Equipment Retrofitting

Facade Restoration

Financial, Investment, Tax or Economic Studies

Forensic/Expert Witness

Hydrology/Water Studies

LEED Certified

Machine, Equipment, or Product Design

Materials Testing/Handling

Nuclear or Atomic Related

Pollution Control/Abatement Services

Precast/Prestressed, or Post-Tension Design

Percolation Testing

Prototype Design

Rehabilitation/Restoration

Seismic Related Services

Site Design

Soils Analysis

Subsurface Conditions/Survey

Turn-Key or Fast-Track Projects

Other

Please explain other special service

Ownership of Projects

Please provide percentages, total to equal 100%

% Contractor

% Government

% Industrial

% Lending Institutions

% Other Design Professionals

% Owners Acting as Own Builders

% Private Clients / Businesses

% Real Estate Developers

% Other

Were 50% or more of firm's gross billings derived from a single client or contract?*

Yes

Project Types

Please provide percentages, total to equal 100%

Airports

Airports - Runways/Taxis

Airports - Terminals

Amusement Parks

Apartments

Bridges/Tunnels/Dams

Commercial less than 50,000 sqft

Commercial greater than 50,000 sqft

Condominiums - Residential

Condominiums - Commercial

Custom Single Family Dwellings

Educational

FHA or other Subsidized Housing

Governmental

Highways/Roads

Hospitals/Health Care

Hotels/Motels - High Rise

Hotels/Motels - Low Rise

Industrial

Jails/Prisons

Library/Museums

Marine

Mass Transit

Offices

Parking Garages

Pipelines

Playground Equipment

Power Plants

Recreational

Recreational - Golf/Parks

Refineries/Chemical Plants

Religious

Residential Subdivision / Tract Homes

Retirement/Convalescent

Sewer/Water Systems

Stadiums/Arena/Convention Centers

Swimming Pools

Toxic/Hazardous Waste Systems

Warehouses

Other

Please describe other Project Types

Project Sizes

List construction value for projects in the past twelve (12) months. (Percentages total to equal 100%)

% Up to $500,000

% $500,000 - $1 Million

% $1 Million - $5 Million

% $5 Million - $10 Million

% $10 Million - $25 Million

% $25 Million - $50 Million

% Over $50 Million

Largest Projects*

Please provide the firm's five (5) largest projects.

Project Name/Location

Client

Project Type

Services

Billings (Current Year)

Construction Value ($)

Start/End Date

Internal Loss Prevention. Does the firm have written procedures for the following:*

Select all that apply

In House quality control procedures

Change Order procedures

BIM quality control procedures or guidelines

Green Design and sustainability quality control procedures

Risk Management Procedures

Screening / pre-qualification of clients, consultants, and contractors

Procedure for monitoring and collecting outstanding fees

None

Does the firm participate in Peer Review sponsored by AIA, NSPE, or other organization?*

Yes

Does the firm have an in-house Continuing Education Program for Employees?*

Yes

List any Professional Memberships, Organizations, or Societies of which the applicant is a member

Cleaning Services Information

Are more than 50 percent of sales generated from operations involving landscaping, lawn maintenance, carpet cleaning, interior painting and window cleaning (combined)?*

Yes

Are more than 50 percent of the total operations dedicated to floor waxing?*

Yes

Are there any operations involving insurance claim response, water removal/extraction, mold remediation, hood/duct cleaning, pressure washing or security?*

Yes

Are there any operations that include “handyman” services, such as electrical, plumbing or carpentry?*

Yes

Are there any operations that include the handling of infectious waste or hazardous material?*

Yes

Are there any operations within auto repair shops, car washes, machine shops, warehouses, manufacturing or industrial facilities (other than cleaning offices within such locations), hotels, college dormitories or schools?*

Yes

Are there any past, pending or planned foreclosure and/or bankruptcy or judgment for unpaid taxes against the named insured or any officer, partner, member or owner, individually within the past five years?*

Yes

Do any operations involve construction debris removal?*

Yes

Do any operations involve street cleaning requiring the use of heavy equipment?*

Yes

Do operations include cleaning of locations (other than personal residences) open 24 hours per day?*

Yes

Events and Party Planners Information

Types of Events*

Please select the type(s) of events you provide and enter the percentage of each type of event.

Event Type

Percentage (%)

Do you own or lease (long term) a hall/banquet facility?*

Yes

What is the square footage of facility?*

Number of Events (current year)*

Number of Events (last year)*

Average attendance per Event*

Maximum daily attendance per Event*

Average length of Event*

Do you sponsor or promote any Events?*

Yes

Please describe event sponsorship or promoting*

Types of Services Provided

Please list the type(s) of services you provide, and indicate if they are performed by your business or provided by subcontractors.

Service

Performed by Applicant

Provided by Subcontractors

Event Equipment*

Do you rent, furnish, or install any of the following equipment? Select all that apply.

Amusement Devices

Barricades

Bleachers

Dance Floors

Folding Chairs/Tables

Sound Equipment

Stages/Staging

Tents

Portable Restrooms

Space Heaters

None

Hold Harmless Agreements*

Do you use standard client contracts with specifies any of the following responsibilities? Select all that apply.

Use of a standard contract which outlines specific responsibilities of your Business

Others holds your Business harmless

Your Business agrees to hold any third parties harmless?

Your Business assumes responsibility, by contract or verbally, for any injury or damage that may occur during event

None

Does the business have any of the following insurance policies currently in force?*

Workers Compensation

Professional Liability

Liquor Liability

None

Name of Liquor Liability Carrier and Limits

Law Firm Information

Type of Law Firm

Is the firm office shared with attorneys other than firm members?*

Yes

Does the firm practice in states other than the primary location?*

Yes

Is the ratio of support staff to attorneys greater than 3 to 1?*

Yes

How many years has the firm been continuously insured for malpractice claims?*

Has the firm ever purchased an Extended Reporting Period option?*

Yes

Does the firm desire coverage for any previously dissolved predecessor firms and those attorneys affiliated therewith?*

Yes

Is there an attorney listed on the letterhead not covered by the firm's insurance?*

Yes

Does the firm or any attorney of the firm have clients in the Entertainment industry?*

Yes

Does the firm have any one client in which the firm's attorney's have an equity interest greater than 10% combined?*

Yes

Does the firm have any one client which represents more than 25% or more of the firm's billings?*

Yes

Does the firm have procedures for identifying and resolving potential or actual conflicts of interest including cross-checking of former, existing, or potential clients?*

Yes

Does the firm have at least two independently maintained docket controls?*

Yes

Does the firm regularly confirm representations in writing via use of formal engagement letters?*

Yes

Does the engagement letter include any of the following?*

Select all that apply

Identity of Client

Scope of Representation that includes key terms of legal representation

Fee structures and billing agreements

Termination agreement that includes file retention and destruction terms

None

Does the firm ensure that a countersigned engagement letter is received from the client before work begins on a new matter?*

Yes

Does the firm regularly acknowledge in writing the declination or termination of representation?*

Yes

Has the firm initiated lawsuits or arbitration procedures during the last two years to enforce the collection of unpaid fees for the firm?*

Yes

Has the Firm or any lawyer in the Firm represented publicly traded clients with services rendered involving Sarbanes-Oxley Act (SOX) compliance including but not limited to Securities, Accounting, Financial/Investment Services or Tax work?*

Yes

Has the firm been involved in any mass tort / class action cases within the past five years?*

Yes

Firm's Gross Revenue (Current fiscal)*

Firm's Gross Revenue (Prior fiscal)*

Firm's Gross Revenue (2 Yrs Prior fiscal)*

What percent of accounts receivable are outstanding more than 90 days?*

Enter firm's insurance history for the last five years

Eff Date

Insurance Company

Limits

Deductible

Covered # of Attys

Annual Premium

Attorneys Information

List of attorneys

Attorney Name	Attorney Designation	Bar member?	Actions

There are no Attorneys.

Maximum number of attorneys reached.

Within the past five years, has any attorney been subject to any disciplinary inquiry, complaint or proceeding for any reason including non-payment of dues?*

Yes

Has any attorney ever been refused admission to practice, disbarred, suspended, formally reprimanded, or sanctioned in any other way?*

Yes

Is any attorney in the firm aware of a professional liability claim made in the past five years against them, the firm, any predecessor firm, or against any current or former attorney of the firm while affiliated with the firm?*

Yes

Is any attorney in the firm aware of an actual or alleged act, omission, circumstance, or breach of duty that a reasonable attorney would recognize might reasonably be expected to result in a claim being made against the firm, any predecessor firm, or against any attorney currently or formerly affiliated with the firm or any predecessor firm, regardless of whether any such claim would be meritorious?*

Yes

Areas of Practice Information

Enter percentages of time devoted (billable hours) in each during the previous year.

Be as accurate as possible, as casual estimates may cause inappropriate evaluation of your practice.

All litigation should be coded as "civil litigation" with the exception of criminal, personal injury-plantiff, and intellectual property, which should be coded to their respective area of practice.

% Admiralty / Marine - Defense

% Admiralty / Marine - Plantiff

% Anti-Trust / Trade Regulation

% Banking / Financial Institutions

% Business Transaction - Comm Law

% Civil Litigation - Defense

% Civil Litigation - Plantiff

% Civil Rights / Discrimination

% Collection / Bankruptcy

% Construction (Building Contracts)

% Consumer Claims

% Corporate Business Organization

% Criminal

% Environmental

% Family Law

% Government Contracts / Claims

% Immigration / Naturalization

% Intellectual Property (Copyright/Trademark/Patent)

% International Law

% Labor Management Rep

% Labor Union Rep

% Local Government

% Natural Resources / Oil & Gas

% Pers Inj / Prop Dam - Defense

% Pers Inj / Prop Dam - Plantiff

% Real Estate / Title - Commercial

% Real Estate / Title - Residential

% Securities (S.E.C.)

% Taxation

% Wills, Estate, Trust & Probate

% Workers Comp - Defense

% Workers Comp - Plantiff

% Other

Building and Property Information

My business location is*

Leased Property

Owned Property

Work From Home

Do you need property coverage for the building?*

Yes

Have you made any tenant improvements?*

Yes

In the future

How much tenant improvement coverage do you need?

Square footage of your business*

Square footage of your building*

Do you have more than 1 business location?*

Yes

Year Built*

Number of stories of the building*

Construction Type*

Roof Type*

Other construction type*

Other roof type*

What type of alarm system does the building have?*

Central Station Alarm

Local Alarm Only

Direct to Police/Fire

No Alarm System

Does the building have a sprinkler system?*

Yes – Fully Sprinklered

Yes – Partially Sprinklered

Additional Business Property Coverages

If you want coverage for any of the areas below please indicate the amount of coverage needed. Otherwise you may skip this section.

Inventory / Stock Amount

Loss of Income Amount

Loss of Rent Amount

Computer Equipment Amount

Portable Equipment Amount

Building Information

Year Built*

Number of stories of the building*

Construction Type*

Roof Type*

Other construction type*

Other roof type*

Has there been any updates to the roof, plumbing, or electrical?*

Yes

I don't know

Year Roof Updated?

Year Plumbing Updated?

Year Electrical Updated?

Additional Location(s)

Locations List

Location Address	Square Feet	Location is	Actions

There are no Locations.

Maximum number of locations reached.

Business Description

Please describe the nature of your business*

Please be descriptive as this will prevent additional underwriting questions and delays.

Please describe the different types of businesses currently operating in the building.*

IT & Technology Information

Do you publish original works or content including software, media, gaming, etc.?*

Yes

Do you provide 3rd parties with any social network, search engine, gambling technology, financial technology, surveillance, white-hatting / ethical hacking, or infrastructure service (except telecommunications), or engage in any activity involving or similar to mining, trading, exchanging, storing, or offering any cryptocurrency, token, digital coin or equivalent?*

Yes

Do you distribute Unsolicited Advertising or Content?*

Yes

Does your business involve obscenity, adult content, or interactions with minors?*

Yes

Do you provide managed services or managed security services?*

Yes

Most recent fiscal year end Gross Revenue*

Most recent fiscal year end Total Expenses*

Revenue from largest contract*

Description of work from largest contract

Does a qualified attorney approve all your contracts, including existing and future contracts?*

Yes

In your contracts do you always cap your Liability?*

Yes

What is the liability cap?*

Do you require legal counsel to review if deviating from your standard terms?*

Yes

Do you have quality control program?*

Yes

Corporate Information

Have you gone through any merger, acquisition, sale of any assets, or other similar transaction within the past 24 months?*

Yes

Do you have any subsidiaries or foreign locations?*

Yes

Do you perform any of the following for third parties: online tracking, data aggregation, data mining, gaming or provide products or services that are specifically intended to enable others to engage in cryptocurrency mining, exchange, trading, initial offerings or storage?*

Yes

Customer Data

What type of customer data do you store?*

Do your products or any of your services perform the following security functions for third parties?*

Identification and Authentication

Intrusion Detection

Monitoring

Other Information Security

None of the above

Please indicate the primary customer industries that you serve*

Examples: healthcare, IT, government, aviation, etc.

Do you have custody of Personal Health Information (PHI) of third Parties?*

Yes

Are you responsible for collecting, storing, processing, safeguarding or any other activity involving the personal information of residents of foreign countries?*

Yes

Number of records you store, collect, process, or otherwise handle from third parties?*

Number of records of Non-public Personal Information (NPI) you collect, store, process, or otherwise handle?*

Which industry standards do you comply with?*

I don't know

PCI/DSS

NIST CSF

SOC 1/2

ISO 27001/2

ISO 8000/1

GDPR

HIPAA

FINRA

FDIC

HITECH

Other

None

Other industry standard*

Who manages you cybersecurity?*

Internal employee

External consultant

None

Do you encrypt all stored or accessed personal data?*

Yes

I don't know

How often do you backup your data*

Daily

Weekly

Monthly

Infrequently

None

I don't know

How long do you retain those backups?*

30 days or more

2 - 30 days

1 day or less

Do you use technical measures, devices or tools and techniques including: firewalls, anti-virus, passwords/authentication, to preclude unauthorized infiltration, modification or corruption of your network, including endpoints and sensitive assets within the network?*

Yes

I don't know

Do you require multi-factor authentication for remote access to your network?*

Yes

I don't know

Do you use any expired or unsupported operating systems or applications?*

Yes

I don't know

Is Remote Desktop Protocol disabled in your network?*

Yes

I don't know

Manufacturing

Is there any manufacturing, mixing, re-labeling, or repackaging of products?*

Yes

Please describe

Tools and Equipment

List tools/equipment and their value*

Human & Social Services Information

Does your business have a state license?*

Yes

State License #*

License Capacity*

Does your business provide child care?*

Yes

Childcare Information

Current maximum number of children you care for at one time*

Does the provider live in the home where the child care is provided?*

Yes

Does the provider provide 24-hour care or overnight care?*

Yes

Does the provider have any swimming facility besides an 18 inch deep plastic wading pool?*

Yes

Does the provider have someone to watch the children in an emergency that causes you to leave the daycare location?*

Yes

Does the provider accept borders in their home?*

Yes

Has the business' childcare license, certification, or registration ever been suspended or revoked?*

Yes

Has the business' childcare insurance ever been cancelled or non-renewed?*

Yes

Has the business had any claims against them in the last 5 years, or do they or their employees know of any incident that could result in a claim?*

Yes

Food & Beverage Information

Area of surrounding premises*

Downtown District

Industrial

Residential/Commercial

Resort

Rural

Seasonal

Shopping Center

Suburban Commercial

Waterfront

None

Does Applicant provide boat docking facilities for patrons?

Yes

How many docking spaces for boats?

Clientele*

Local Residents

Families

Retirement Community

College Students

Seasonal Residents

Are premises located near a college or university?

Yes

Does Applicant have or sponsor any "Teen" or "Under 21 nights" or permit patrons under the age of 21 in a bar area after 11pm?

Yes

Hours of Operation

Seating Capacity

Number of Staff

Average Meal Price

Annual Gross Sales

Liquor Sales (past 12 months)

Liquor Sales (next 12 months)

Food Sales (past 12 months)

Food Sales (next 12 months)

Gambling Sales (past 12 months)

Gambling Sales (next 12 months)

Catering Sales (past 12 months)

Catering Sales (next 12 months)

Other Sales (past 12 months)

Other Sales (next 12 months)

Does applicant have a parking area?

Yes

Are facilities available for use or rent for private parties, receptions, or similar affairs?

Yes

Are any animals, including dogs, allowed on the premises?

Yes

Does applicant serve any raw shellfish (including oysters)?

Yes

Does the applicant import any food products?

Yes

Have there been any health code violations in the past 3 years?

Yes

Is smoking permitted on the premises?

Yes

Cooking

If no cooking check here

N/A

# Ovens

# Grills

# Commercial Ranges

# Tableside Cooking

# Deep Fat Fryers

# Microwaves

# BBQ Pits

# Other Equipment

Are customers allowed to cook their own food?

Yes

Are there functioning smoke or heat detectors used in all public areas?

Yes

Safety & Security

Is there more than one means of egress from the premises?

Yes

Are the means of egress clearly marked and kept unlocked during business hours?

Yes

Are employees trained for evacuation?

Yes

Emergency lighting in all common areas (including stairwells)?

Yes

Are police records and background checks conducted on employees?

Yes

Security/crowd management control?

Yes

Does applicant have a written Sexual Harassment policy?

Yes

Entertainment

Is there any live entertainment on premises?

Yes

Number of times per week

Type of Music

Select all that apply

Country

Rock

Hip Hop

Rap

Jazz

Classical

Other

Is there dancing?

Yes

Does applicant have any mechanical or amusement devices?

Yes

Are there sports on the premises?

Yes

Does applicant sponsor any special events?

Yes

Is there any gambling?

Yes

Does applicant have any of the following exposures:

Select any that apply

Alcohol without liquid (AWOL)

Firearms

Oxygen Bar

Ultimate Fighting or "Rage in the Cage" contests

Moon bounces, Trampolines, or Rock Walls

Swimming Pools

Pyrotechnics, Foam Machines or GERBS

Retail and Ecommerce

Describe the type(s) of products you sell*

Do you sell any food products, or products designed for consumption?*

Yes

Do you sell chemical and cleaning products?*

Yes

Do you mass manufacture any products?*

Yes

Do all products sold adhere to all applicable safety, labeling, disclosure and consumer protection requirements in the jurisdiction they are sold?*

Yes

Please indicate whether your business is selling, re-selling, manufacturing, or distributing any of the following:*

Select all that apply

Alcohol

Weapons or personal defense devices

Tobacco

Cannabis including CBD, or products containing Cannabis or CBD

Adult material

Pharmaceuticals homeopathic, herbal remedies, nutraceuticals, contraceptives, nutrition, dermabrasion products, hair regrowth treatment/products or diet supplements

Electronic cigarettes (e-cigarettes), vaporizers, or e-cigarette components and accessories, including any products containing diacetyl

Medical devices including orthopedic shoes

Nutraceuticals or supplements that contain ingredients considered "dietary supplements" by FDA and/or Health Canada

Animal feed, animal or animal parts, including skins or furs

Safety Equipment, Protective Equipment, Excise Equipment, or any mission-critical systems or components

Personal Protective Equipment (PPE), including but not limited to latex gloves and hand sanitizer

Building construction materials, products containing asbestos, motorized vehicles, heavy machinery, or tools and equipment containing motors

Farming supplies, Pesticides, herbicides, or fertilizers (including manure)

Children's products as defined by CPSC and/or Health Canada including but not limited to toys, children safety devices & equipment, furniture or sleepwear intended for infants or children

E-Scooters or Hoverboards

Tree stands

Magnet sets or individual magnets

Goods valued at $100,000 or more

Electricity generators, hair dryers, extension cords, surge protectors or power strips, cell phones

Lithium-ion batteries, lithium-ion battery components, or lithium-ion chargers that (1) are refurbished, (2) are intended for products with total battery capacity exceeding 100 watt-hours, (3) draw more than 12 amps of electrical current, or (4) are not Underwriters Laboratories (UL) certified, Canadian Standards Association (CSA) certified, or Edison Testing Laboratories (ETL) certified

Combustible or highly flammable items including but not limited to acetone, aerosol, alcohol, butane, methane, propane, firepits, gel fuels and gel candles

Heating devices including but not limited stoves, space heaters, ovens, electric grills, toasters, pressure cookers, terrarium heat lamps, fireplace inserts, fireworks/explosives, gas cans

None of the above

Where do you sell your products?*

Select all that apply

Physical retail store (brick and mortar)

Independent website

Amazon

eBay

Etsy

Facebook / FB Marketplace / Instagram

Google / Google Shopping

Walmart / Jet.com

Shopify storefront

Other

Do you directly import finished goods from outside of the United States?*

Yes

Do you or your business create, manufacture, design, relabel, private label, or make any modifications to products sold?*

Yes

Liability Limits (optional)

What is the Liability limit requested?

Do you need any Business Personal Property coverage?*

Yes

Not sure, let's discuss

How much Business Personal Property coverage do you want?

Are you interested in Loss of Use / Business Income coverage?*

Yes

Not sure, let's discuss

Garage & Dealers Information

What types of vehicles you service, repair, or sell?*

Select all that apply

Private Passenger

Motorhomes

Motorcycles

Utility Trailers

Commercial Trucks

Commercial Trailers

Other

Other vehicles*

What is the total amount of coverage for other people's vehicles would you like?*

Example: If you have 20 vehicles at any one time and each vehicle has an average value of $25,000 then you would want $500,000 in coverage.

What parts and accessories do you sell over the counter?

None

New Parts

Used Parts

Exterior/Interior Trim

Apparel

Estimated annual over the counter sales

What are your security practices?*

3-Part Ticket

Key Cabinet

Protected Lot

None

Where do you store customer's vehicles?*

In Building

Fenced Area

Open Lot

Where do you store keys to customer's vehicles?*

Key Cabinet

In/On the Vehicle

Vehicle Mounted Lockbox

Taken Home

Other

Please describe Other key storage location*

If keys are stored in a vehicle mounted lockbox, are keys or lockboxes removed from the vehicles and stored inside after hours?*

Yes

Do you park customer vehicles on the street?*

Yes

Do you conduct towing operations?*

Yes

Are vehicles loaned to customers?*

Yes

Do you have a contract with customer, and get a copy of insurance, and a copy of drivers license?*

Yes

Do you ever store or display autos at a different location or lot other than where you conduct business?*

Yes

Please provide details of where and how often*

Is your business involved with any racing or exhibitions?*

Yes

Racing and Exhibitions Information

Do you have any owned vehicles used for racing or exhibitions?*

Yes

Is the vehicle titled in the name of the business?*

Yes

Do you service any vehicles involved in racing or exhibition events?*

Yes

Please describe work performed and location where work is performed*

Do you sponsor any racing related activities?*

Yes

Please describe sponsorship related activities*

Do you sell, install, or service racing tires?*

Yes

Garage & Dealers Information

List the percentage of the work you provide for each section below.

Where work is performed. Total must equal 100%.

Percent of work performed at Your Shop

% at Your Shop

Percent of work performed at Customer's Location

% at Customer's Location

Percent of work performed at Other

% Other

Please describe Other Location

Type(s) of work performed (in percent). Total must equal 100%.

Type of Work: Body/Paint

% Body/Paint

Type of Work: Brakes, Transmission or Suspension

% Brakes, Transmission or Suspension

Type of Work: Electrical

% Electrical

Type of Work: Mechanical

% Mechanical

Type of Work: Muffler/Radiator

% Muffler/Radiator

Type of Work: Oil Change

% Oil Change

Type of Work: Roadside Assistance

% Roadside Assistance

Type of Work: Safety Inspection

% Safety Inspection

Type of Work: Tires/Wheels

% Tires/Wheels

Type of Work: Tune Up

% Tune Up

Type of Work: Wash/Detail

% Wash/Detail

Type of Work: Welding

% Welding

Type of Work: Other

% Other (Upholstery, frame work, body work, window tint, windows, cleaning trailer, stereo system, etc.)

Please describe Welding type of work performed*

Please describe Other type of work performed*

Do you provide any off-site services or mobile services?*

Yes

What is the maximum miles away from your business that you offer your services?*

Dealer Sales Questions

% Vehicle Sales (Retail)

% Vehicle Sales (Wholesale)

% Vehicle Sales (Broker)

Number of Dealer Plates (Autos)

Number of Dealer Plates (Motorcycles)

Number of Dealer Plates (Boats)

Number of Dealer Plates (Trailers)

Number of Repairer/Transporter plates owned by you?

What states are you licensed in?

Number of vehicles sold annually*

Number held for sale (Average #)*

Number held for sale (Maximum #)*

Number of vehicles sold on internet auction

Number of vehicles sold on consignment

Do you sell "salvage titled" vehicles?*

Yes

Yes: How much structural repair done?*

Do you lease, rent or loan Dealer, Transporter, or any other type of plates?*

Yes

Do you lease or rent vehicles?*

Yes

Do you import or export vehicles?*

Yes

Do you operate an auction?*

Yes

Do you sell gasoline?*

Yes

Do you sell Liquefied Petroleum Gas (LPG)?*

Yes

If you paint, do you have a spray paint booth/separate room?*

Yes

Do you provide electric charging station for your customers?*

Yes

Do you sell tires?*

Yes

Do you service any tires?*

Yes

Media and Advertising

Is your business, or the business of your subsidiaries, affiliates, parent company, or any of your clients involved with any of the following below:

Do you use a written contract or agreement for services with your customers?*

In all cases (100%)

Most of the time (between 75% and 99%)

Sometimes (between 1% and 74%)

Never (0%)

Are contracts reviews by a legal department or a third party law firm?*

Yes

Do contracts include indemnification clauses in your favor?*

Yes

Do contracts clearly state the ownership rights, licensing, and use of any materials or intellectual property created for or during an engagement?*

Yes

Not Applicable

Media and advertising involving Cannabis?*

Yes

Media and advertising involving production or distribution of Adult Content?*

Yes

Own, operate, or derive revenue from thermal coal-fired power plants, thermal coal mines, arctic energy exploration activities, oil sands or controversial weapons (e.g. cluster bombs, anti- personnel mines, chemical or biological weapons, or other weapons identified by applicable international treaties and conventions)*

Yes

List of websites you seek coverage and average number of monthly hits for each

Website URL

Average Monthly Hits

Do you permit 3rd parties to upload music, videos, or other content on your website(s)?*

Yes

Do you maintain the right and ability to control the material that users publish or upload onto your website(s)?*

Yes

Do you have procedures in place to remove or disable access to material on your website(s) when you become aware that such material infringes another's intellectual property rights?*

Yes

Do you dictate in any manner the form or substance of content that is posted on your website(s) by third parties?*

Yes

Do you require third-party content providers to transfer ownership or other rights in their content to you?*

Yes

Do you publish newspapers, magazines, or digital publications?*

Yes

Are you involved in broadcasting activities?*

Yes

Publishing and Digital Activities

Percentage of gross revenue comes from publishing*

List newspapers, magazines, digital publications you publish

Name and Type

Nature of Content

Frequency

Ave. Circulation

Circulation Area

For content created by you, provide percentage of each type of content

Select all the type(s) of content you create and the percent created of each

Genre

% of Content

Broadcasting Activities

Name of station*

(call letters)

Medium of broadcast*

Hours of broadcast per week*

Peak audience figure*

Geographical market*

Nature of broadcast*

% news originated by you

% third party news wire service

% third party network affiliate

% third party freelancers, stringers, or other non-employees

% undercover / investigative reporting

For live broadcasts, is there a time delay of at least 7 seconds?

Yes

N/A

Do you have any discussion / phone-ins / live / unscripted programming

Yes

Do you have any on air personalities / DJ considered a 'shock jock'?

Yes

Is any media published, broadcast, or communicated in a language other than English?

Yes

Additional Insured Information (optional)

Do you have anyone that needs to be listed as Additional Insured?

Yes

Additional Insured Information. (i.e. Name & Address)

You may upload your additional insured documents using the upload field below.

Additional Insured Document(s)

You may upload up to 10 PDF documents. If you have more documents you can send them to your agent after they contact you.

Drop files here or

Accepted file types: pdf, Max. file size: 20 MB, Max. files: 10.

Prior Insurance (NEMT)

Have you had previous insurance for this enterprise?

Yes

Please attach 3 years of General Liability, Professional and Commercial Auto loss runs.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 20 MB.

Have you or anyone for whom coverage is being requested ever had a liability insurance application denied, or had a policy cancelled or non-renewed in the past three (3) years?*

Yes

Please provide full details.

Claims Information (NEMT)

During the past three (3) years, have any claims been presented to your current or prior insurance carrier(s)?

Yes

What was the date, amount paid, and description of each loss or claim?

Are you or anyone for whom insurance is being requested, aware of any circumstances which may result in a claim?

Yes

Please provide full details.

Claims Information

Have you had any claims or losses in the last 5 years?*

Yes

What was the date, amount paid, and description of each loss or claim*

Has your business been cancelled or non-renewed in the last 4 years?*

Yes

Have you ever filed for bankruptcy?*

Yes

Bankruptcy: Please describe when and why*

Do you have ANY business insurance currently?*

Yes

Do you have ANY previous business insurance from the past 3 years?*

Yes

Current Insurance

Name of current insurance carrier?*

Expiration date of current policy*

MM slash DD slash YYYY

Current total insurance premium?

Current Policies

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB, Max. files: 10.

Prior Insurance

Please enter your prior business insurance information below.

Prior Carrier Name 1

Policy Year 1

Premium 1

Prior Carrier Name 2

Policy Year 2

Premium 2

Prior Carrier Name 3

Policy Year 3

Premium 3

Additional Comments and/or Documents (optional)

Any additional comments

Any Additional Documents

Drop files here or

Accepted file types: pdf, Max. file size: 8 MB, Max. files: 5.

Wrapping Up

Consent*

Like most insurance agencies, we use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.

I Agree

All the above information is accurate and true to the best of my knowledge.*

Yes

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Yes, create my account

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