Skip to content
7761 Ballantyne Commons Parkway, Charlotte, NC 28277
[email protected]
Home
About Us
Services
Insurance Coverage Matching
Policy Binding & Financing
Ongoing Insurance Management
Insurance
Insurance
Commercial General Liability
Property Insurance
Commercial Auto Insurance
Workers’ Compensation
Professional Liability (E&O)
Cyber Liability Insurance
FAQ
Contact Us
Home
About Us
Services
Insurance Coverage Matching
Policy Binding & Financing
Ongoing Insurance Management
Insurance
Insurance
Commercial General Liability
Property Insurance
Commercial Auto Insurance
Workers’ Compensation
Professional Liability (E&O)
Cyber Liability Insurance
FAQ
Contact Us
Standard Quote
Call Now
(888) 629-3134
Express Quote
Simplified Insurance Application
Home
Simplified Insurance Application
Legal Name:
Federal Tax Id:
Mailing Address
City
State
Zip Code
Location Address
City
State
Zip Code
Telephone
Email Address
Web Address
Fax
Contact Name
Years Business
Effective Date of Coverage
Property
Property
Estimated Value
Business Personal Property
Business Personal Property
Estimated Value
Inland Marine
Inland Marine
Estimated Value
General Liability
General Liability
Limit
Crime
Crime
Limit
Excess and Umbrella Liability
Excess and Umbrella Liability
Limit
Garage Keepers Liability
Garage Keepers Liability
Limit
Workers Compensation
Workers Compensation
Limit
Commercial Vehicle
Commercial Vehicle
Limit
Professional Errors & Omissions
Professional Errors & Omissions
Limit
Product Liability
Product Liability
Limit
End Date in 12 months?
Yes
NO
Construction of Building
Brick
Non-Combust
Frame
Metal
Concrete
Etc
Replacement Value of the Structure
How Many Stories
Are you the sole user of the building?
Yes
No
Total Square Footage of building:
Square Footage you will occupy:
Description of Fire Protection
Where is the nearest Fire Hydrant
Fire Department
Description of Security
What is the designed use of your building
Office
Warehouse
Retail
Research Lab
Etc
When was the building constructed?
Have there been any renovations, if so then what year?
Wiring
Heating/Cooling System
Roof
Plumbing
Is the facility subject to additional Governmental Agency controls and/or restrictions (EPA, FDA, etc.)?
Description and replacement value of Business Personal Property (Tools, Equipment, Computers, Furniture, all company assets):
Description of Operations (What do you do, and who are your typical customers):
Is your company a: Corporation, LLC, Individual, “S” Corp, Joint Venture, Non-Profit, Trust
How many employees do you have?
If subs are used, what are your annual subcosts?
How many customers generate the total annual revenues for your company?
What is your total payroll?
What are the projected annual revenues for your company?
What are your most significant exposures as you see them?
Your description of operations will direct the next wave of questions and open conversations on Product Liability and/or Professional errors & Omissions Liability Insurance.
Additional Insured, Loss Payee, Mortgagee need to be added?
Yes
No
Name
Address
Interest
Please provide a Schedule of Vehicles including the following
Year
Make
Model
VIN
Cost New
Comp/Collision Ded
Do you obtain Motor Vehicle Reports (MVR) on all employees that drive vehicles on behalf of the company?
Yes
No
Please provide the most current report.
Does your vehicle have a wrap or any other permanent alterations? If so, what was the cost?
Please provide approximate radius of transport operations
Please provide 3-year loss run reports for the respective insurance companies.
Please provide current Driver’s List: Attach if more space needed
Name
Date of Birth
Driver’s License #
State Licensed
What Is your company: Corporation, LLC, Individual, “S” Corp, Joint Venture, Non-Profit, Trust?
Federal Tax Id:
What is your Experience Mod (if applicable)
Desired Workers Comp Limits
Desired Workers Comp Limits
$100,000/$500,000/$100,000
$500,000/$500,000/ $500,000
$1,000,000/$1,000,000/$1,000,000
What States do you operate in?
Are the Owners Included or Excluded:
Included
Excluded
Please provide Name, Date of Birth of owners
Name
Date of Birth
Regarding Workers Compensation, do you know how your employees are or will be classified?
Yes
No
If yes, then please provide your class codes and the respective payroll per each code below
Class Code
Address Location
State
# of Full Time/ # of Part Time Employee
Total Payroll
Please provide Loss Runs for the past 3 years (current insurance company will have this report).
Do we have permission to review your loss history including experience modification worksheets through various sources?
Yes
No
Submit
