Form 2 – Golden Compress Insurance Service

Company Information - Step 1 of 11

What is the name of your business? *

Doing Business As

I have a DBA name

DBA Name

What is the zip code of your primary business location? *

When did you start your business? *//

When would you like your policy coverage to start? *//

What types of insurance do you need?

General Liability
Business Owners Policy (General Liability and Business Property Coverage)
Errors & Omissions / Professional Liability
Workers' Compensation
Cyber Liability
Commercial Auto

First name

Last name

Phone number *

Email *

Primary

Primary contact is the business owner

How is your business registered?

Association
Individual
LLC
Limited Partnership
Non-Medical Homecare
Corporation
Joint Venture
Partnership
Trust
S Corporation

FEIN or SOC. SEC#

Number of Owner

Number of employees

Do you have a website?

Is the applicant a subsidiary of another entity? *

First

Middle

Last

Does the applicant have any subsidiaries? *

First

Middle

Last

Has applicant had a foreclosure, repossession, or bankruptcy in the past 5 years?

Has applicant had been indicted for or convicted of any degree of fraud, bribery, or arson-related crimes?

Has applicant had any fire/safety code violations, judgements, or liens in the past 5 years?

Nature of Business

Apartments
Condominiums
Contractors
Institutional
Manufacturing
Office
Restaurant
Retail
Service
Wholesale
Other

How many locations are on the policy?

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Address 2 *

Address Line 1

Address Line 2

City

State

Zip Code

Address 3 *

Address Line 1

Address Line 2

City

State

Zip Code

What is the Total Insurable Value (Buiding, if any, + *BPP, if any) for all locations?

What is the highest TIV at any single building?

Primary

This is the mailing address

Projected sales for the next 12 months

Total Payroll

Annual payroll for your field employees Do not include owners/officers, or office/clerical employees

Total Annual Receipts

Annual payroll for your field employees Do not include owners/officers, or office/clerical employees

Business Operations

Number of contractor licenses you currently hold

Is general liability/property insurance coverage currently in effect? *

Is workers' compensation insurance coverage currently in effect? *

Is automobile insurance coverage currently in effect? *

Has your general liability or property coverage been declined, canceled or non-renewed within the last 3 years? *

Has your workers' compensation coverage been declined, canceled, or non-renewed within the last 3 years? *

Has your company had any claims in the past 3 years? *

Named Insurer *

General liability limit

$1,000,000/$2,000,000
$2,000,000/$4,000,000

Property deductible

$250
$500
$1000
$2500
$5000
$10000

Business personal property limit

Do you own or rent?

Own
Rent

Include building coverage

Area occupied by insured *

Construction type

High rise building
Low rise building
Low rise brick or concrete block
Low rise wood structure

Steel grade used in building

Heavy steel
Light steel

Masonry grade of building

Reinforced masonry
Other than reinforced masonry

Number of stories

Year built

Building is 100% sprinklered

What type of fire alarm does your building have?

Central station
Local
None

What type of burglar alarm does your building have?

Central station
Local
None

Enter either the VIN to automatically fill in vehicle information, or manually enter the year, make, model of the vehicle:

Enter VIN
Enter Make/Model

VIN

Vehicle Category

Auto
Pickup/Van/SUV
Commercial Truck
Trailer

Vehicle Type

Vehicle Cost New

Gross Vehicle Weight

Does this vehicle have a telematics system installed (either factory or after-market)?

Is this vehicle being used for business or personal use? (Check all that apply)

Business Use
Personal Use

What is the farthest one-way distance this vehicle is driven from its principal garaging location?

Is this vehicle individually owned?

Purchase Type

Owned
Leased

Who is the vehicle registered to?

Named Insured
Lessor

Location

Registration State

Comprehensive Deductible

No Coverage Requested
$100
$250
$500
$1000
$2500
$5000

Collision Deductible

No Coverage Requested
$100
$250
$500
$1000
$2500
$5000

Year

Make

Model

Body Style

Driver #1

Date of birth//

State Licensed

Drivers license #

Gender

Male
Female

Marital status

Divorced
Domestic Partner
Married
Separated
Single
Widow

Relationship to insured

Insured
Other
Spouse

Driver status

Owner driver
Owner excluded driver
Employee driver
Employee excluded driver
Relative driver
Relative excluded driver
Occasional or temporary driver

Date licensed

Driver license status

Has a Commercial Driver's License (CDL)

Liability Limit

No Coverage
$100,000
$300,000
$500,000
$1,000,000

Medical Payments

No Coverage
$500
$1,000
$2,000
$5,000
$10,000

Towing

No Coverage
$50
$100

Rental reimbursement per day

No Coverage
$30
$40
$50
$75
$100

Rental reimbursement number of days

No Coverage
30
45
60
90

Requires a certificate of insurance to show coverage for "Any Auto" by any client(s)

Do you rent or plan on renting heavy or extra-heavy vehicles (gross vehicle weight of more than 20,000 lbs)

Do you use any of following types of labor? (select all that apply)

Day laborers or unskilled workers
Subcontractors

Do operations include installation, service, or repair?

Performs installation, service, or repair work (including subcontractors)

Do business operations include the following? (select all that apply)

Custom interior woodworking (trim, built-ins, cabinetry, hardwood flooring installation)
Exterior carpentry additions (decks, porches, garages/sheds)
Home additions (room or square footage expansions, bump-outs)
Interior room remodeling/renovating (aesthetic improvements to kitchens, baths, basements)
Outdoor living (stone/concrete patios, outdoor kitchens, hardscaping)
Whole-home renovations (major interior renovations)
Builds cabinets
Currently performs work involving new residential properties prior to the certificate of occupancy or plans to in the future
EIFS work (past or present)
Erects grandstands or bleachers
rects wooden bridges, derricks, or platforms
Handyman services
Hod hoist or construction
Roofing
Specializes in erection of scaffolding
Structural framing
Hardwood floor refinishing or installation
Electroplating/anodizing

What do your excavation operations involve? (select all that apply)

Dredging
Wrecking or demolition

Which of the following apply to your business operations? (select all that apply)

Salvage operations

Which of the following apply to your welding operations? (select all that apply)

Work involves burning, welding, using fire or spark producing tools, or that produce a source of ignition

Do your business operations include any of the following? (select all that apply)

Closed or temporarily suspended and not expected to be open within the next 30 days
Employees enter occupied customer residences
Extermination or pest control
Machines used in the scope of your operation
Motor vehicles used for business purposes
Performs exterior work underground or above ground level
Rents or loans equipment to others
Railroad construction
Restoration work
Seasonal operations (facility is closed for 3 or more months)
Silo or grain elevator construction
Tower erection, maintenance, or demolition
Union operation
Windmills (wood)
Performs design, construction, installation, removal, or physical repair of any property or tangible good

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/remediation
Lead paint removal
Radon remediation or measurement
Radon remediation or measurement
Pools, playgrounds, or amusement rides
Oil, gas, or wells

Where will you perform services?

Airport facilities
Hospitals, clinics, or assisted living facilities
Outside your domiciled state within the last 3 years
Utilities, bridges, tunnels, or elevated highways
Work in or around dams or rivers

Do any of the following apply to your business? (select all that apply)

Written safety program
Owner carriers their own health insurance coverage
Return to work program

Do any of the following apply to the business owner or business?(select all that apply)

Owns more than 50% of a business other than the business described in this application
Has subsidiaries
Operations sold, acquired, or discontinued in the past 5 years
Indicted for or convicted of any degree of the crime of fraud, bribery, arson, or any other arson-related crime during the last 5 years (10 in RI)
Bankruptcy, tax or credit lien within the last 5 years
OSHA violations in the past 3 years
Involved in any loss or litigation regarding poor workmanship, construction defect, water intrusion, mold or fungi (including work by subcontractors) or has knowledge of existing problems or defects that could give rise to future claims

Do any of the following apply to the business? (select all that apply)

Owns, operates or leases aircraft
Owns, operates or leases watercraft
Past, present, or discontinued operations involved in storing, treating, discharging, applying or transporting hazardous materials
Work on barges, vessels, docks or bridges over water performed
Group transportation provided
Employees under 16 or over 60 years of age
Employees travel overnight
Employees travel outside the country (other than Canada) for business purposes
Employees are leased from a PEO (Professional Employment Organization) or leased to other companies or business on a permanent or temporary basis

Do you have/allow any of the following on business premises? (select all that apply)

Hazardous waste cleaning, removal, or operations

Do any of the following apply to the business? (select all that apply)

Does NOT always obtain written contract prior to starting any work
Security controls do NOT include encryption of mobile computing devices
Does NOT maintain weekly backups of all sensitive or otherwise critical data and all critical business systems offline or on a separate network
Does NOT enforce procedures to remove content (including third party content) that may infringe or violate any intellectual property or privacy right
Does NOT require a secondary means of communication to validate the authenticity of fund transfers (ACH, wire, etc.) requests before processing a request in excess of $25,000

Do any of the following apply to the business? (select all that apply)

Has been the subject to any complaints concerning website content, advertising materials, social media, or other publications in the last 3 years
Stores, processes, transfers or transmits Payment Card Information (PCI), Personally Identifiable Information (PII), or Protected Health Information (PHI)

Commercial Auto

Does NOT have formal preventative vehicle management program in operation
Does NOT provide initial driver training to all drivers when first hired
Does NOT have a seat belt policy
Does NOT have a cell/texting policy
Vehicles are NOT primarily used by employees
Does NOT review employee driving records for acceptability/prescreen MVRs for employees and volunteers who drive company vehicles on an annual basis
Vehicles leased to others
Drivers are covered by workers' compensation
Transports or delivers goods of others using owned vehicles
Has a USDOT
Requires state or federal filings (Filings would include Federal Filing, MCS90 Filing, State Filing and Other Filing. This does not include SR-22 Filings.)