from – Golden Compress Insurance Service

What is the name of your business? *

Doing Business As

I have a 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 contact is the business owner

Do you hold a specialized license?

Do you perform home remodeling that requires a permit or build ground-up new construction?

Which of the following apply to your operations?

Home remodeling
New construction
Both

Is remodeling limited to non-structural interior work?

Residential work

Commercial work

Total

$ 0.00

Number of Owner

Number of employees

Do you Have a website?

In a few sentences, describe your business and key business operations.

Address line 1 *

Address line 2 *

Zip

City, State *

This is the mailing address

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? *

Is workers' compensation coverage currently in effect? *

Is commercial auto coverage 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? *

General liability limit

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

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

Year

Make

Model

Body Style

Driver #1

Date of birth//

State Licensed

Drivers license #

Gender

Male
Female

Relationship to insured

Insured
Other
Spouse

Date licensed

Driver license status

Has a Commercial Driver's License (CDL)

Requires SR-22 filing

SR-22 case number

Towing

No Coverage
$50
$100

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)

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 jobs involve or expose employees to the following? (select all that apply)

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)