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Company Information
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Step
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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?
*
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When would you like your policy coverage to start?
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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
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First name
Last name
Phone number
*
Email
*
Primary contact is the business owner
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Do you hold a specialized license?
Yes
No
Do you perform home remodeling that requires a permit or build ground-up new construction?
Yes
No
Which of the following apply to your operations?
Home remodeling
New construction
Both
Is remodeling limited to non-structural interior work?
Yes
No
What type of interior carpentry work do you perform? (select all that apply)
Cabinetry
Drywall
Hardwood floors
Painting
Replacing fixtures
Trim work
Residential work
Commercial work
Total
$ 0.00
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How is your business registered?
Association
Individual
LLC
Limited Partnership
Non-Medical Homecare
Corporation
Joint Venture
Partnership
Trust
S Corporation
Number of Owner
Number of employees
Do you Have a website?
Yes
No
In a few sentences, describe your business and key business operations.
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Address line 1
*
Address line 2
*
Zip
City, State
*
This is the mailing address
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Projected sales for the next 12 months
Payroll
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?
*
Yes
No
Is workers' compensation coverage currently in effect?
*
Yes
No
Is commercial auto coverage in effect?
*
Yes
No
Has your general liability or property coverage been declined, canceled or non-renewed within the last 3 years?
*
Yes
No
Has your workers' compensation coverage been declined, canceled, or non-renewed within the last 3 years?
*
Yes
No
Has your company had any claims in the past 3 years?
*
Yes
No
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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
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
$125,000
$150,000
$175,000
$200,000
$300,000
$400,000
$500,000
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
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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
Select Vehicle Type
Passenger auto
Luxury auto
Sport auto
Ultra auto
Mini van - cargo
Mini van- passenger
Full size van - cargo
Full size van - passenger
Pickup 1/2 ton or less 2wd
Pickup 1/2 ton or less 4wd
Pickup greater than 1/2 ton 2wd
Pickup greater than 1/2 ton 4wd
Premium SUV
SUV
Boom truck
Car carrier
Car carrier 1 rear axle
Car carrier 2 rear axle
Catering truck
Dump truck
Flatbed truck
Refrigerated truck
Stake body truck
Step/delivery van
Tank truck > 1400 gallons
Tow truck 1 rear axle
Tow truck 2 rear axle
Concession trailer
Enclosed utility trailer less than 12 feet
Enclosed utility trailer 12 feet or more
Gooseneck trailer
Horse trailer
Large horse and utility trailer
Livestock trailer
Open utility trailer < 12 feet
Open utility trailer 12 feet or more
Vehicle Cost New
Gross Vehicle Weight
Does this vehicle have a telematics system installed (either factory or after-market)?
Yes
No
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?
Yes
No
Purchase Type
Owned
Leased
Who is the vehicle registered to?
Named Insured
Lessor
Location
Registration State
Alabama
Alaska
Arizonа
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Kentucky
Maine
Maryland
Massachusetts
Michigan
Minnesota
Missouri
Mississippi
Nebraska
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
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Driver #1
Date of birth
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1920
State Licensed
Alabama
Alaska
Arizonа
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Kentucky
Maine
Maryland
Massachusetts
Michigan
Minnesota
Missouri
Mississippi
Nebraska
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Driver license status
Cancelled
Expired
International License
Not/Never Licensed
Revoked
Suspended
Surrendered
Temporary
Unknown
Has a Commercial Driver's License (CDL)
Requires SR-22 filing
SR-22 case number
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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)
Yes
No
Next
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.)
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